‘Condition Haych’ – An Epidemic of Grammatical Proportions

In a recent publication in the Journal of Speaking Properly (Spurr 2014), epidemiologists suggested we are in the midst of an epidemic. Public health officials are relatively confident that the disease known as ‘Condition Haych’ is largely isolated to the Australian population at present (urgent amendment see below for update).

‘Condition Haych’ is a disease characterised by the mispronunciation of the letter ‘H’ – correctly orated as ‘Aych‘ (note the absence of preceding H).

Although the authors were unable to establish a definitive genetic link, the disease process trended toward association with environmental and lifestyle factors. Correlation with other symptoms, such as cognitive inability to distinguish between ‘their‘, ‘there‘, and ‘they’re‘; and ‘your‘ and ‘you’re‘ were statistically significant (p<0.01).

While not a terminal disease, recovery is rare and requires extensive rehabilitation with speech pathology involvement and extreme negative conditioning cognitive behaviour therapy.

I would like to thank my wife for the inspiration to write this review, she is in remission following aggressive therapy for this debilitating illness.

 

http://www.youtube.com/watch?v=c3y0CD2CoCs

Grammar: the difference between knowing your shit, and knowing you’re shit.

28th June 2014 Urgent Post-publication Update: In the past three days, confirmed cases of Condition Haych have flooded in via Injectable Orange Centre for Disease Control (aka Twitter). There have been widespread reports of Haych-like symptoms in the United Kingdom and a number of verified cases of Condition Haych in Nova-Scotia, Canada thanks to our epidemiologist on the ground @VasospasticRN. I will keep the public updated as information comes to hand.

Resuscitative Fluid Therapy – Get it in quick?

Bolus: a large dose of a substance given by injection for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream. (Merriam-Webster Dictionary Online)

Watering bike

Get those fluids in STAT

Consider a case. You are called to see a patient.

68 year old lady.

Day one post-operative phase following right total hip replacement.

Documented Operating Room notes as ‘oozy’ operation.

Tachycardiac, hypotensive, dry mucous membranes ECG normal Sinus Tachycardia, normothermic. Moderate haemoserous loss via drain.

Decision made to give 500ml intravenous crystalloid bolus.

500ml is diligently dialled up on the infusion pump to the maximum flow rate (1000ml/hr) and ‘start’ is pressed.

Is this resuscitative fluid therapy? Is it a fluid challenge? Has the goal of therapy been defined?

Are we going to be able to assess for a significant response to these fluids?

As a critical care nurse I am amazed at how frequently in a ward context, compromised, hypotensive and clinically dry patients receive an infusion rather than the requested bolus. I am also equally as surprised that the prescribing medical officer, unless directly asked ‘how fast do you want it in?’ will not specify, yet when prescribing maintenance fluids, will diligently document a precise order of 42ml/hr.

This post is really intended to stimulate some thought about the logistics and human factors that dictate what version of an immensely common therapeutic action our patient receives.

As an in-hospital Medical Emergency Response Nurse, I am routinely employing the probing question of ‘how fast would you like that fluid administered?’ I also attach an addendum – ‘do you want it over half an hour, or would you like to pull it out of the pump so we can give it quicker, evaluate the response and you can work through some other things?’

In terms of practicalities in the delivery (lacking the presence of a medical or nursing student) – a pressure bag will free up a pair of hands from squeezing the IV fluids in by hand. In the absence of this purposefully designed solution, I have often used a manual BP cuff, wrapped firmly around the upper half of the bag and then pumped up.

BP Cuff

BP Cuff = Excellent Pressure Bag

Pressure bag

Actual Pressure Bag

Both of these options are great because you are able to observe the pressure registered by the cuff on inflation and have an estimation as to the amour of force being exerted to the forward flow against the patient’s own BP and tubing resistance. It is important to note, this does not absolve us from monitoring the patient’s response and observing the IV catheter site, but frees up a pair of trained hands to do some more meaningful (even if it is hold the patient’s hand and reassure them, explaining what is happening).

I have attached an list of my favourites for recommended reading/viewing below. These resources have all improved my understanding of the humble fluid bolus.

An elegantly simple description by Haney Mallemat @criticalcarenow

Excellent explanation of the details of a ‘Fluid Challenge’

http://lifeinthefastlane.com/education/ccc/fluid-challenge/

A great compilation of evidence and FOAM links relating to assessment of fluid responsiveness.

http://lifeinthefastlane.com/education/ccc/fluid-responsiveness/

A thought provoking and enigmatic discussion on fluids in sepsis from Paul Marik, nicely moderated by Scott Weingart @emcrit

http://emcrit.org/podcasts/paul-marik-fluids-sepsis/

 

SMACC Chicago 2015 – Don’t Make Other Plans

I know there are much more high profile websites than injectable orange publicising SMACC 2015. But this conference will be of such epic proportions that it deserves every digital footprint it gets. So… print this poster, make a point of telling your colleagues about this amazing opportunity to learn and build professional friendships. I am also absolutely thrilled that my reflection on SMACC Gold (2014) features on the save the date poster.

 

 

http://intensivecarenetwork.com/smacc-chicago/

http://lifeinthefastlane.com/save-date-smacc-chicago/

http://prehospitalmed.com/2014/05/25/smacc-chicago-2015-book-leave-now/

Plants in Simulation

The following video presentation is a brief overview of the role of the confederate in simulation. Quite simply, the confederate is one of the best tools I have found in the quest to enhance the fidelity/realism for participants in immersive simulation. I will be presenting soon at the Laerdal SUN Conference – giving a workshop on In Situ Simulation for Patient Safety – ‘Waking Sleeping Giants’ and this video is going to be given as part of a flipped workshop approach in pre-attendance. It’s my first attempt at a screen recording and I learned a great deal (mostly how not to do it next time). I would love for others to share your experiences in simulation or in production of better quality videos than mine. I am really keen to learn.

http://www.youtube.com/watch?v=tQNRKqEaLMg

References

Sanko et al. 2013 Establishing a convention for acting in healthcare simulation: merging art and science.

 

What Happens When You Work With Warring Tribes?

Slide1

My first reaction when asked to write a piece for Injectable Orange was almost embarrassment that someone felt I had something to contribute to this up swell of amazing nursing and medical blogs that have changed the way I think about reflective learning over the last 3 years.  This was quickly followed by an overwhelming feeling of terror – what the hell am I going to say?

After a few weeks of contemplation I decided to take some inspiration from the opening address at the recent SMACCGOLD conference. The incredible Victoria Brazil spoke about the concept of various teams in a hospital being like tribes: the ED tribe, the ICU tribe, the Cardiology tribe, and the various nursing, medical, and allied health tribes. During this presentation a case was laid out detailing perhaps not the best way to navigate through the various tribes of the hospital with their respective cultures and languages to achieve primary coronary angioplasty for a patient presenting with an acute myocardial infarction.

As the laughs and head shaking continued in the audience whilst this case unfolded, in my mind on loop playback was ‘welcome to my daily practice as an ICU Outreach nurse’. I am often asked, ‘what exactly does an ICU Outreach nurse do?’ My response is usually a mixed bag, there is something relating to assessment of the deteriorating patient. I am part of the medical emergency team and to a large degree I am an educator. The one thing I am always sure to explain is that I act as a pivot to ensure the right clinicians are involved in a deteriorating patient’s care to intervene and hopefully change this patient’s clinical course. Another question I am frequently asked in my line of work is ‘how did you manage to get “them” to listen to you when it comes to escalating the care of deteriorating patients?’ This is something I have struggled to answer, but thanks to Victoria’s presentation and a little book called Tribal Leadership, by David Logan, I have come to a better understanding of how I achieve this task. A function which can be so difficult at times. More importantly I have reflected on how I can continue to improve on the vital skill of communicating.

funny-war-jet-missiles

David Logan describes organisations and subsets within these organisations as a tribe. A tribe as a group of 20 to 150 people who know one another well enough that if they saw each other walking down the street, they would stop and say ‘hello’. I thought about this from a ward perspective It’s the nurses, doctors and allied health teams you work with every day, not the ‘tribe’ that works 2 floors down with a different specialty to your own. It’s the nursing staff, whom see their role completely separate to that of the medical staff.

This book then goes on to describe what makes an effective tribe, culture. This culture is a product of the language people use and the behaviours that accompany those words. The nursing staff don’t suggest interventions, the resident dutifully scribes the notes on rounds but lives by the adage ‘been seen and not heard’, the graduate nurse who is worried about her patient’s respiratory rate of 30 but has been told before that is fine on this ward. So what happens when we need something from another tribe? My medical patient needs a surgical review. The in-charge nurse is justifying a 1:1 nurse ratio for an unwell patient and needs medical documentation, but the medical team don’t agree?  In most cases, it is what I like to call war; different tribes, with different cultures and language at the end of a bed. How do you strive for the common goal, when you are from a different culture and speaking a different language? David Logan describes the five stages of tribal cultures that evolve from individual focused behaviours and language. Tribes who strive to be the best against the competition give way eventually to the tribes that can work with almost anyone to achieve the common goal and compete only with what is possible. Sounding like a hospital near you yet?

These five stages of tribalism gave me the insight to understand that I was able to have effective conversations and escalate care because, before having the conversation, I take the time to think about where the other individual was coming from. I pause to consider whether they are an intern that had been sent by the registrar with orders to ‘sort it out’, but whatever you do don’t bring the patient back to ‘my ward’. Are they the ward charge nurse, that has just been pushed to take three patients from the emergency department under the threat of the 4hr Rule and I was asking her to make a bed for the fourth sick patient. I have taken the time during those rare quiet shifts to get to know the tribal chiefs and understand their cultures.

In my role as an ICU Outreach nurse, I realised I had been striving to be a Tribal leader. David Logan describes this as a very personal journey and to get there you must do the “prep work” on yourself first, including:

  • Learn the language and customs of all five cultural stages.
  • Listen for which tribal members speak which language – in essence, who is at what stage?
  • Move yourself forward, start talking a different language and shifting the structure of relationships around you.
  • Take these actions as you upgrade the tribe around you.

There is so much to this concept that lends itself to the way we work as healthcare professionals, the next time you feel like you are going to war, I challenge you to consider the language and culture of the other team, changing yours may just get you to the common goal.

What happens when you work with warring tribes?

I guess I am lucky enough to be bilingual.

 

Poor Man’s “High” Flow Nasal Oxygen

 

 

 

The evidence around high flow humidified nasal oxygen in adult patients is developing, although the physiological mechanisms remain poorly understood. Instead of replicating information relating to the performance and summary of mechanisms, I’d encourage you to check out this very succinct and thorough overview from the LITFL Critical Care Compendium.

Although I am the first to acknowledge that in an adult population, the beneficial effects (CPAP/PEEP) of flow are demonstrated at flow rates of 50-70L/min, many wards/departments/units/regional hospitals don’t have sufficient equipment (gas blender, etc.) to produce/regulate these types of flows. So the purpose of this post is to demonstrate how to achieve up to 30L/min flow at up to 0.60 FiO2 with a standard humidifier, two-pronged plastic connector (Batman connector) and a humidified oxygen circuit with High Flow Nasal Cannula such as the Fisher Paykel Optiflow system.

Below is a set-up diagram of the components in the system, which I have been referring to as Ward “High” Flow.

Standard Flow 15L Air + 15L Oxygen Humidified Ward ‘High’ Flow

So, why bother you ask? There is a very apparent gap in the admitted inpatient medical emergency setting when it comes to the adult patient in respiratory distress (high work of breathing) requiring high concentration oxygen. The generic process (from experience in Medical Emergency Teams at 3 different hospital I have worked in) is:

Patient dyspnoeic with low SpO2 = 15L/min Oxygen delivered via Non-Rebreather Mask or Partial Rebreather achieving an FiO2 somewhere in the range of 0.65 to 0.90. If Therapy is instituted,the underlying cause is addressed and the patient responds to treatment (read: bronchodilators, ventilators, diuretics and repositioning), the oxygen is weaned and the patient is returned onto simple nasal cannula or room air. There is limited insult to mucocilliary mechanisms and everyone breathes a collective sigh of relief and the MERT is over.

But what about those patients that just don;t get better that quickly. I have seen many situations when the patient is left at the end of our swag of usual interventions, improved somewhat, yet still dyspnoeic with high oxygen demands and limited respiratory reserve. Should this 97 year old man, who is not a candidate for ICU, nor would he wish for that, be left on 10-15L/min face mask oxygen languishing with moving goalposts of ‘aim for SpO2 of….insert declining number below 90%’? Or is there something relatively cheap, easy and evidence based we can do? This is not an isolated case. Nor is it the only useful application for a simple ward based “High” flow solution.

The key benefits are that, in the acute phase, this setup can achieve 30L/min flow. This flow more comfortably meets increased respiratory demand, provides a moderate degree of CPAP effect (depending largely on Nasal Cannula fit) and aids with nasopharyngeal washout of expired carbon-dioxide. The setup also provides heated humidified gas – facilitating secretion clearance.  All these factors can bridge that uncomfortable distance between the ward and the ICU.

When have I suggested this option? Many times.

If a patient is describing feeling flow starved – ‘I’m not getting any air’ and there is ongoing respiratory distress, with increased work of breathing past the immediate treatment phase and, for whatever reason, this person is not going down the path to intensive care, consider this option.

As a crude guide, my experience (almost unequivocally) has been that when applied as indicated, transition from 15L/min face mask oxygen results in improvement in SpO2 within 2-5 minutes, decreased work of breathing, respiratory rate and increased patient reported comfort within 5-10 minutes and all with a reduction in FiO2.

This is not a common therapy in any hospital I have worked in. Beyond the set-up of the circuit, the major issue is the continuity of this therapy as the flow rates don’t easily calibrate with our common experiences and mental computation of FiO2 delivered by different oxygen devices. This is why I have written this post. The below table is a correlation of fraction of inspired oxygen with the dialled-up flow rate from Air and Oxygen. I hope this can aid the ongoing management and remove some of the hesitation around utilising this very easy and beneficial therapy.

Fraction of Inspired Oxygen Related to Dialled-Up Flow Rates

 

I have no conflicts of interest to disclose and have referred to Fisher Paykel only because these are the products with which I am familiar.

For more information, indications and rationale please check out the links within this post. If you use this set-up, please get in touch and let me know your experiences.

 

Added References

Clinical Evidence Summaries (F&P)

Nasal high-flow therapy delivers low level positive airway pressure