Thread by @GongGasGirl

Watching this broadcast from yesterday about unrecognised oesophageal intubation. Lessons from the coroner. Why does it still happen?

https://twitter.com/Anaes_Journal/status/1471869950113497097

Panel has three professors @drlauraduggan Prof Pandit @ProfAndyS. Chaired by @Miko_Charleswor who appears to be wearing a beard, a Christmas Jumper and a Christmas elf.

Paper discusses the tragic case of an unrecognised oesophageal intubation leading to cardiac arrest and death. Routine operation (appendicectomy) for a women with no significant medical issues. Routine airway management, no difficulties expected.

Coroner's reports have three reasons for unrecognised oesophageal intubation:

1. CO2 monitor either not used or not available
2. No trace, wrong place (lack of CO2 trace wrongly interpreted as cardiac arrest instead of oesophageal intubation).
3. Failure to look at CO2 trace.

This case didn't have CO2 trace on the monitor. Default setting gave the pressure waveform instead. Easy to mixup waveform interpretation if they are not where they are expected.

(I often worry about too many monitors/lines/complexity distracting from the most important ones).

Prof Duggan says 'heartbreaking lack of basic monitoring'. That anyone should be able to walk into that room and expect that the monitor is set up consistently in each theatre.

Prof Pandit says we have to facilitate a safety culture. This could happen to anyone. No judgement. The equipment, infrastructure around should facilitate safety, it shouldn't fall on the human element to be the safety barrier.

MC asks was the apparent simplicity of the case a contributor? JP says perhaps we need an optimum state of arousal / stress to achieve peak performance (although AS notes that many psychology experiments conducted on rats, or perhaps psych students, can we in fact extrapolate?)

Anaesthesia requires a team says AS. Works well with familiarity. With a shared situational awareness. When working with different teams, need to be more explicit, and then even more so in an emergency.

This patient was initially intubated by an assistant using DL. What is the role of trainees here? Yes, we have an obligation to teach, however must be within a framework of education and safety with patient consent. Not just 'I'm here to intubate'.

LD notes that in closed claims cases, interestingly it is in fact the more routine / elective cases which feature strongly; over and above emergency / difficult airway cases.

(I'm reminded that there is not such thing as 'just a quick' anything ...)

Commentary around psychological safety / hierarchy in the workplace. Can you ask a question without being seen as being ignorant? Can you question policies without being seen as being a trouble maker?

We need to set up organisations that work in the patients best interest.

LD notes completely different culture in medicine across Canada. Notes nurses assist in airway mgmt in Ottawa. Everyone trained in capnography. Nurses take great pride in getting a great waveform during preoxygenation. Then nurse and anaes confirm together the trace post tube.

The nurse will just say 'there's no capnography'.
No ego no hierarchy.

MC wonders if the hierarchy in the UK, with all the different anaes grades, is holding back patient safety. JP says the titles are shorthand, the rank implies a certain set of skills. However, these titles have been blurred, can be unclear who has what set of skills.

JP also says that even if the titles are accurate, they shouldn't create the hierarchy. Shouldn't inhibit speaking up for safety. Not easy to achieve both of these aims.

How can we convey seniority but without creating psychological barriers?

MC notes we are trained to call for help from early on in anaes training, the suggestion is to go further, to elaborate on what kind of help is needed. In this case, there were many senior people available, but their purpose wasn't immediately apparent.

Sometimes the help needed is obvious (eg massive blood loss) and everyone just gets on with it, sometimes not ...'I just don't know what is going on ... can you help me understand what is wrong here'.

Also the attendees can also check themselves on arrival that all is ok, don't assume that all the primary anaesthetist says is true ...

LD wonders is our system all wrong. If I'm diagnostically exhausted or no insight (don't call for help) ... should that person be in charge of calling for help? Can we design a better system.

Three problems:
1. The person who won't call for help.
2. The person who will call for help, but won't say what they need
3. The person who will call for help, but specifies the wrong help needed

Should there always be an n + 1 anaes available? To come and provide immediate help in an emergency.

However the system may say 'we are employing an anaesthetist to 'do nothing'.

(Here we are lucky we have a duty anaesthetist main floor public, however not elsewhere).

AS says he asks for help more often now that he has more experience.

(Me too, I just want all the heads together, I'm quick on the emergency buzzer, quick to get mates thinking through problems with me).

More people involved = better outcome, everyone learns. In some small places, folk sniff out a problem and come and help without asking.

Why would you not want to work with someone else when things are stressful?

AS notes in addition to purpose, also important to say how urgently you need help. ISBAR model vs traffic lights (green = bit of advice; vs red = need you now).

(Also impressed with AS's twitter skills these days - has kindly put the link to the Cook traffic light paper up).

Here we go, inevitable move to VL to DL.

LD says we should start with VL, and then move to DL (not the other way around).

LD also notes 'direct laryngoscopy' no good .... can't see a damn thing bouncing around their shoulder .... VL also gives trainee much more time...

LD says all her trainees use VL with her (unless senior anaes trainees). She insists on it.

'It's time to adopt the automatic car'.

So how do we prevent unrecognised oesophageal intubation?

1. Capnography education and training
2. Embed personalised rituals for airway mgmt (clinical checks - chest rise, tube mist, listen)
3. Smart monitoring with directed alarm (combine pressure and CO2 monitor)

Unrecognised oesophageal intubation could happen to any of us. One of the most feared complications of anaesthesia.

Waveform capnography essential for every intubated patient at all times everywhere.

There is no replacement for waveform capnography.

AS says we should practise: 'civilised worry.

Any patient can go wrong with any anaesthetist.

Thank you to Prof Pandit @ProfAndyS @drlauraduggan @Miko_Charleswor for a very helpful broadcast.

Lessons for all of us.

Thinking of the family and friends of Glenda May Logsdail who sadly died under general anaesthesia in August 2020.

Thank you to those who investigated her tragic death, and now provide us with this report to prevent future deaths.

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