Two different emergency cases…

The 43 years old man is about to be intubated for a routine operation. The experienced anesthesiologist does not expect this sudden difficult airway that the patient presents with now. “Difficult airway”, the doctor says loudly, clearly, and quickly – you can hear his stress and the anesthesia nurse in the room knows her and knows: now it counts. “Get the crash trolley and prepare for a cricothyrotomy. Help me also with pushing the larynx. Best get help.” The nurse hesitates briefly to prioritize, then calls for help into the hallway, where he knows, a colleague should be free. Then he rushes to push the larynx and holds half an eye on the colleague entering the emergency room to ask her immediately to bring the cric set.

The ambulance crew arrived really quickly. They grab their gear and enter the house. The door is open, as announced by the dispatcher. They see the patient – a 17 years old girl, curled up in pain, and begin with their clinical assessment along the ABCDE structure. That is until the mother of the patient returns from the kitchen with a glass of water. She is in tears, and shouts and pleads to help her only daughter. Never before has she seen her in so much pain and is terrified by the thought of losing her. The paramedics look at each other and make a plan. One looks at the mother, places a hand on her shoulder and calmly says: “Look at me. In order to help your daughter, we need space to work and time to think. We need you to help us by explaining what l you know . Let’s go over into this corner of the room here. You can see everything, but I can understand you better. OK?” Her firm calmness spreads, the mother stops screaming and follows with shaking hands into the corner, where she and the paramedic can hear. “Airway clear. Breathing 19 per minute…”

Reflective thoughts on the cases

Both cases are emergencies. But they are very different. Different because of the people involved, the task to be performed, and the challenges to overcome.

In the first case, except for the patient, all the people involved are trained professionals. They can cover for their respective glitches – where the nurse prioritizes the three tasks he is asked to do at once. The anesthesiologist stays in working mode, even though she is tense and even though the situation turned upside down in the blink of an eye. Not many words are needed, the communication is efficient. The task to be done is amongst the most time critical maneuvers in healthcare and it is clear what to do. Air needs to get into the patient, and there are well known, escalating options, which all can be implemented once the crash cart is close by. Clear what to do – but do it quickly. And share the mental model of urgency with few words. The challenge lies in a potentially difficult psychomotor task to be performed, while knowing that the life of this patient is at stake. It is keeping enough of an overview to optimize the conditions – by getting help – so that the full concentration can be on the maneuver. It also means to prepare for a task that triggers about all human reflexes, shouting: do not do this. Taking a knife and cutting into the throat of a human being. Luckily, swift coordination helps in avoiding the need to do so.

In the second case, the professionals meet two more persons. The patient and her mother. The professionals are visitors in the setting and never know what to expect. They are in a foreign environment potentially in danger and need to assess every new person entering the scene also in regards to posing a threat to themselves. This is not the case here, but the mother brings in such a strong change in situation that the paramedics decide – relying on very implicit communication – to split the work. One working with the patient, focusing on the well trained approach to patients in a systematic fashion. What the actual problem is, the reason for the pain of the patient is unclear at the moment. As opposed to the first case, here the paramedics need to define it first based on the findings they make. The other paramedic switches gear in an instance. She focuses completely on the mother. By focusing on the mother, by reacting calmly and yet firmly, she manages to get the mother out of panic. She involves the mother, by asking for help and more information. Her reasoning seems to work: Investing a few moments of unshared attention might get the mother out of her panic. Then the paramedic will be able to join her teammate again in the treatment. Without a panicked mother to fight off. The paramedic uses a lot of her personal resources and trusts the process. It feels strange to leave her partner and the patient to deal with the distraction that the mother poses. But she knows that this is likely the quickest way to be helping the patient again soon, and her partner knows it as well.

Learning needs for emergency situations/emergencies?

Together, the cases show that emergency situations can present and unfold differently, and we only sketched two possible situations out of myriads that happen every day. The SAFETY+ is about trying to understand different types of emergencies and what they require of healthcare professionals. A situation that requires a lot of diagnostic steps to discover what the actual problem is poses different challenges than a situation that requires delicate hand-eye coordination and dexterity under time pressure that stems from a patient potentially dying in a matter of minutes.

The cases also show how complex the technical and so called “non-technical” skills need to flow into each other and work with each other to allow for the best treatment of the patient. SAFETY+ is also about refining our understanding of this delicate interplay – especially when it is about working with patients and their relatives in a constructive way.

An emergency team needs different specialists to handle different tasks in emergency situations/emergencies. But what is the perfect/ideal emergency team composition? Which specialties are required/necessary to optimize treatment in different situations? SAFETY + is also about defining the ideal emergency team composition.

As addressed in the case description, the outcome is based on the training level of the professionals involved – both on diagnostic and psychomotor skills and on coordination and communication skills. SAFETY+ will analyze the training necessities and training methodologies for interdisciplinary emergency healthcare teams, in order to provide a most efficient and effective training for them.

Team composition, training of individuals and teams, interplay of technical and so called “non-technical” skills – this is what SAFETY+ will address and enhance Europe-wide.

Written by Peter Dieckmann, Camilla Normand, Une Stømer, Nina Vatland, and Thor Ole Gulsrud from the University of Stavanger and Marc Lazarovici from the Ludwig Maximilians University of Munich

Contact: peter.dieckmann@uis.no

Photo credits: www.safer.net