What Happens When You Work With Warring Tribes?

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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

 

 

Life, Death and God in ED

I am incredibly excited to welcome Patrick Bafuma on board as a guest author to Injectable Orange. Patrick is an Emergency Medicine Physician Assistant in Hudson Valley, New York. This role was quite foreign to me before “meeting” Patrick. The physician assistant practices medicine under the supervision of a Physician or Surgeon with a similar scope to an early training resident Doctor, but with a vastly greater contextual experience in their field of employment. This brings a unique and interesting experience and perspective to Injectable Orange. Patrick writes punchy, succinct articles grounded in mini-literature reviews on topic and contextualised to his experience (see more at EMinFocus.com).

Enjoy – Jesse (@inject_orange)

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If you have worked in the Emergency Department long enough, you readily recognise the patients that are imminently going to die.  The young man with a herniating bleed, normotensive and beginning to become bradycardic.  Stage IV colorectal cancer, with free air under her diaphragm.

I’ve often half-jokingly stated that we treat our pets better than our family at the end of life.  Our beloved Fido dies after a run on the beach, a steak dinner, and with a slug of morphine….  Grandma?  She gets intubated without pain medication, gags a bit, and likely dies in significant distress.

We CAN make this process more peaceful.  There is a significant movement for emergency medicine to OWN palliative care.  We need to recognize when heroic efforts will go for naught (1 year mortality for a patient >85 years old admitted to the ICU is 97%).  We can be soothing.  We can start Fentanyl drips.  We can add anti-secretory agents.  We can deliver on anxiolysis.

As per a recent study, according to the family of the deceased:

‘What factors were associated with the perception of peaceful death?’

Adequate personal attention.

Adequate personal care.

Family finds enough nurses available.

And ability to make a phone call.

Religious affiliation consideration in end-of-life decision making has been associated with the perception of a peaceful passing.  Simply offering a chaplain to come in for support, often times is soothing to the family and facilitates a sense of closure.  There is something about the end of a loved one’s life that brings out an inner spirituality from both atheists and believers.  This is so simple to do!  If the RN asked me if they could page the chaplain for my dying patient, I would be embarrassed I had yet to do it myself.  It is one of few things that we may all do that has been shown to influence a family member’s perception that their loved one passed peacefully.

Next time it appears futile, think benefits versus burdens. As the end-of-life discussion occurs, offer a chaplain.  The conversation and the weight of reality is never going to be easy for the family.  Let’s make an honest attempt to make it less difficult.  Let’s turn off the monitor, turn on the Fentanyl drip, load the patient with Hyoscine, and bring the chaplain into your team.

 

When do people with dementia die peacefully? An analysis of data collected prospectively in long-term care settings

PMID:24292158

 

Outcome of elderly patients with circulatory failure.

PMID: 24132383

FOAM & Social Media: The New Learning for an Old Generation

I am an old school nurse of the generational belief that the old ways, once learnt, are the right way, and the way it should be forever more.

Social media platforms such as Facebook and Twitter are just a perverted way of checking out whether old school friends and ex-girlfriends had aged as horribly as you had hoped they would. A way for the young kids to ‘have a voice’ and ‘be heard’ as well as bully their peers and show ‘selfies’ that would make Larry Flint blush.

Blogs are a way for blowhard, pontificating celebrities to tell us how to live our lives; to be green; and to save creatures none of us have heard of, let alone ever seen.

Podcasts are how I could listen to my favourite comedians, or learn how to run 5kms in a matter of weeks.

How is any of this relevant to me in my professional life and ability to progress my career? Why do I need to know about this passing fad? I am happy with my knowledge. Journals and textbooks keep me up to date. I don’t need to stay young by keeping up with the kids!

3p43Hzt8sA-2

One day, about three years ago, my friend Luke was espousing the values of Twitter as a platform for some new ways to access learning tools. Sceptical, but identifying my need for some new ways to present my teachings, I begrudgingly signed up. Immediately I was exposed to a whole world of people willing to share their thoughts and opinions in 140 characters.

I found a whole new universe of links and websites that aided me in honing my craft, packing an educational punch like the big boys (and gals). TEDtalks blew me away. I was able to redefine my presentation style in ways beyond endless PowerPoint slides and YouTube clips.

The other upside was the access to current and cutting edge information, right now. And for free! Free, I tells ya! This wonderful and well researched information that I was able to incorporate and impart was magnificent (and made me seem instantly smarter – if not more attractive).

Then, another day a few years later, my friend Jesse convinced me to check out his blog. I was impressed. Well thought out and cleverly presented nursing concepts that I had long thought too dry to take much interest in. Once Injectable Orange found it’s way onto the FOAMed map, my professional world went into overload. I realised there was unlimited access to other blogs, websites and podcasts allowed me to keep myself current with the thoughts, trials and tribulations of others around the world. My peer review network expanded exponentially! And it was accessible across professional streams, something previously thought to be taboo in healthcare.

To finally round off this shift in my learning attitude, I was fortunate enough to meet some of these people at the SMACCGold conference this year. To find such knowledgeable people, who are so happy to freely impart their thoughts and experience is a truly humbling experience. I dare not name them for fear of leaving someone off the list. These people really put the humanity back into healthcare.

I was an old school nurse of the generational belief that the old ways, once learnt, are the right way, and the way it should be forever more. I have since seen the light.

You can teach an old nurse new tricks.

Many thanks to @lukie27 and @Inject_Orange for setting me on this path of FOAM enlightment.

 

FOAM & Social Media: The New Learning for an Old Generation

I am an old school nurse of the generational belief that the old ways, once learnt, are the right way, and the way it should be forever more.

Social media platforms such as Facebook and Twitter are just a perverted way of checking out whether old school friends and ex-girlfriends had aged as horribly as you had hoped they would. A way for the young kids to ‘have a voice’ and ‘be heard’ as well as bully their peers and show ‘selfies’ that would make Larry Flint blush.

Blogs are a way for blowhard, pontificating celebrities to tell us how to live our lives; to be green; and to save creatures none of us have heard of, let alone ever seen.

Podcasts are how I could listen to my favourite comedians, or learn how to run 5kms in a matter of weeks.

How is any of this relevant to me in my professional life and ability to progress my career? Why do I need to know about this passing fad? I am happy with my knowledge. Journals and textbooks keep me up to date. I don’t need to stay young by keeping up with the kids!

3p43Hzt8sA-2

One day, about three years ago, my friend Luke was espousing the values of Twitter as a platform for some new ways to access learning tools. Sceptical, but identifying my need for some new ways to present my teachings, I begrudgingly signed up. Immediately I was exposed to a whole world of people willing to share their thoughts and opinions in 140 characters.

I found a whole new universe of links and websites that aided me in honing my craft, packing an educational punch like the big boys (and gals). TEDtalks blew me away. I was able to redefine my presentation style in ways beyond endless PowerPoint slides and YouTube clips.

The other upside was the access to current and cutting edge information, right now. And for free! Free, I tells ya! This wonderful and well researched information that I was able to incorporate and impart was magnificent (and made me seem instantly smarter – if not more attractive).

Then, another day a few years later, my friend Jesse convinced me to check out his blog. I was impressed. Well thought out and cleverly presented nursing concepts that I had long thought too dry to take much interest in. Once Injectable Orange found it’s way onto the FOAMed map, my professional world went into overload. I realised there was unlimited access to other blogs, websites and podcasts allowed me to keep myself current with the thoughts, trials and tribulations of others around the world. My peer review network expanded exponentially! And it was accessible across professional streams, something previously thought to be taboo in healthcare.

To finally round off this shift in my learning attitude, I was fortunate enough to meet some of these people at the SMACCGold conference this year. To find such knowledgeable people, who are so happy to freely impart their thoughts and experience is a truly humbling experience. I dare not name them for fear of leaving someone off the list. These people really put the humanity back into healthcare.

I was an old school nurse of the generational belief that the old ways, once learnt, are the right way, and the way it should be forever more. I have since seen the light.

You can teach an old nurse new tricks.

Many thanks to @lukie27 and @Inject_Orange for setting me on this path of FOAM enlightment.

 

Irish Jellybeanery and the Man that Makes Everyone Smile

Doug-Lynch

Last year I met Doug Lynch (@thetopend). Doug is one of those rare people who lives out his own genuine philosophy. An honest, heart on his sleeve type fellow, disarming, charming and by his own admission a suitable helping of bonkers. Sometimes you meet someone and instantly feel like you’ve known them for a long time. Doug has finally started up his own blog dedicated to his Jellybean vox pop style interviews that have become somewhat legendary following their birth at SMACC 2013. I can only liken Doug’s interview style to that of Between Two Ferns (if you haven’t seen it you’re missing out). I am looking forward to exploring the wild and wonderful mind of this great man.

Please go and have a good read at: http://thetopend.org

So as somewhat of an anti-climax to this post, here is a recent Jellybean in which, following much arm twisting, I ended up with an audience of one in a breakout room between sessions at SMACCGOLD. I had fun and felt quite humbled to be Jellybeaned.

For a full back catalogue compendium of Doug’s Jellybeans check out Life in The Fast Lane.