🧵 Managing Challenging Behaviours in Resuscitation Teams: A Thread for Team Leaders (1/13)

Every resuscitation team leader can face difficult team dynamics

Here are 6 key challenging behaviours you'll encounter and how to manage them effectively in real-time 🚨 The Dominant/Overconfident Member 🦁 (2/13)

- Takes over without authority
- Dismisses others' input
- Makes unilateral decisions

Solution: Acknowledge expertise and redirect energy to specific tasks "Thank you Dr. Smith, I need your expertise on airway management right now."

Extubation Readiness: A to L Checklist

We're obsessed with safe intubation, but what about taking the tube out?

How do we assess extubation readiness?

Here's my simple, alphabet-based A to L checklist:

1/17 A - Airway: MAINTENANCE & PROTECTION

Check:

Neuromuscular tone (correlates with consciousness)

Risk of airway swelling (prolonged intubation, difficult intubation, burns) - consider cuff leak test (deflate cuff and assess for leak. Dexamethasone might be indicated)

2/17

Early 40s male with chest pain and collapse, looks horrible, SBP 80, lactate 7.
Previous large PE with pulmonary hypertension on echo 2 months ago, discharged on apixaban
POCUS on arrival shows:



The POCUS findings are consistent with cor pulmonale but in view of his previous echo, how do we know this is the acute cause of his shock? Should we thrombolyse?

Here’s how I think we often fail our patients when treating ’sepsis’

a 🧵

1/11 In my capacity as both an emergency medicine and intensive care specialist I’ve observed that we sometimes:

- 1. Inappropriately diagnose other shock states as sepsis

2/11

WTF is a ‘difficult airway’?

A 🧵

1/14 I avoid the term ‘difficult airway’ altogether

How we describe a situation can have a psychological framing effect that can affect our performance

2/

Let's review an intubation together - a 🧵 A previously well patient in her 60's presents with a first seizure & post-ictal coma
A nasopharyngeal airway has been placed for airway patency
She weighs 100kg
She receives 70mg propofol /100mg rocuronium after checklist completion, pre-ox & application of nasal cannula O2

Stopping someone from bleeding to death requires many keys steps

Our team uses this cognitive aid

Page 1 covers general measures to guide vascular access, haemostatic resuscitation, reversal of anticoagulation, and optimising of clotting

1/10 Page 2 gives specific guidance on managing the location of haemorrhage, eg. epistaxis, haematemesis, etc

2/10

Very short🧵on AF in hospital 1/5

Atrial fibrillation in hospital often starts from interplay between underlying risk factors (substrate) & acute triggers The 3 A's of acute management are

1. Acute trigger identification & management

2. AF rate/rhythm control

3. Anticoagulation - BUT:...

2/5

The iGel is a great supraglottic airway device

But like other supraglottic airway devices (SAD) it's not foolproof

Here's how to maximise your success with the iGel - a thread 🧵 Adequately positioned SADs produce a good seal and no leak

Three #cardiology cases with diagnostic ECGs in our resus room today and some learning points for emergency clinicians

#ecg #ekg 1. Sudden onset palpitations

ECG shows regular narrow complex tachycardia with rate around 140

Over the last couple of decades my colleagues and I have analysed HUNDREDS of resuscitation cases and here are the THREE things you need to master to save more lives 1. Airway management. You need checklists, videolaryngoscopy, waveform capnography, and an airway registry to enable you to review and share airway QI data

Moments in the Jurassic Park Emergency Department

- a 🧵 Brave RN goes out to 'pacify' the waiting room with an update on waiting times

Last night we had a case that demonstrates an extremely important cause of shock that many ED clinicians know little or nothing about

1/ Complex patient presented following a fall. Rib fractures, CKD, ‘cardiomyopathy’, AICD/PPM, mild cognitive impairment

Tachycardic (126 regular) and hypotensive. Initially fluid responsive then BP dropped again

No trauma related source of hypotension on CT

HEY RESUSCITATION ROOM & ICU NURSES

This long 🧵is for YOU

It is about your VALUE & your IMPORTANCE. Something I believe SO passionately & isn't broadcast from the rooftops loud enough or often enough, which it should be. So I'm here to yell it in your & your colleagues' faces It may appear a bit Australia-specific but applies equally to overseas resus nurses, physician assistants, & acute care practitioners, as well as critical care, coronary care, & operating room nurses, & flight paramedics who work in physician-staffed HEMS

Here's a reflection on how the management style of the emergency physician in charge (EPIC) can mean the difference between life and death

(Long 🧵) In overwhelmed systems (EDs in every English speaking nation) the EPIC is constantly tortured by the conflict between maintaining the overview & being available to answer Qs & guide her team on the one hand, & picking up her own cases on the other hand to make a dent in the queue

1/ This Tweet has been called out as divisive and on reflection I think that’s correct

I haven’t deleted it because there are thoughtful responses that deserve to remain aired

The Tweet was poorly worded and fails to capture the nuance of what I was trying to convey

https://twitter.com/cliffreid/status/1312371016040022019

2/ There’s obviously nothing wrong with calling ICU colleagues about sick pts

I don’t care which specialty intubates patients- that’s a matter for local resources and governance

Resus is small % of our total patient load. We do have to triage our staffing resources accordingly

1/6 After >1 year of long service leave I returned to prehospital & retrieval medicine last night for a
@SydneyHEMS night shift, and was sent on two fairly gnarly prehospital missions: one complex paediatric medical (helicopter) and one adult bariatric entrapped trauma (road) 2/6 I’m still reflecting on what it was that made me love being back so much - far more than I expected to - but there’s no doubt three major factors contributed to my exhilaration:

1/
HOW ELSE TO REDUCE RISKS TO YOUR ED STAFF

Important to consider alternatives to CPAP/BiPAP in patients with other cardiorespiratory presentations who may also have COVID-19 2/ Some of us are old enough to have managed patients very successfully before we had NIV in the ED

Important to pass our experience on to younger colleagues

1/
Intubation of #COVID19 Patients

We are sharing our resources in the hope that some of the ideas and processes will be of use to other units who don’t yet have systems fully in place.

**Please read the rest of the thread first** 2/
We have simmed the bejeezus out of this in ED, Wards, and ICU every day for 1.5 weeks.

The system is currently based on availability of our negative pressure rooms which we realise will run out very quickly.

Feel free to use/share/learn from but bear the following in mind:

1/12
A quick reflection on inspiration and motivation for clinicians involved in resuscitation 2/
I want to share how and why I’m inspired by my colleagues.

My favourite educational activity is digging deep in analysing difficult resuscitation cases