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CCP Sam Immens presented a great talk outlining a simple but effective method to perform Clinical Reflection. The following blog post explains this method.
What is Reflection and Why Should We Do It?
Clinical reflection is a tool that enables the individual to learn from their experiences and actions. This involves building the tools to learn self reflection in order to master the technical and non-technical aspects involved in high performance teamwork.
Clinical reflection has benefits in helping to improve memory forming and storing as well as building mental resilience. It forms part of a larger guided mentoring program for professional development and deliberate practice.
Ideally it should be performed more than twenty-four hours after the job to give time for thought processing, however before seven days when memory degradation starts.
How Should We Do It?
This process takes practice, the first one is always hard but it does get easier.
Sam’s Recorded Talk:
Sam’s talk was recorded on the day and can be viewed below, using the YouTube link.
Want to Find Out More?
There’s more on the benefits and challenges of reflection for healthcare providers here:
Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.
Sydney HEMS is proud of its commitment to excellence in airway management. In 2020, we achieved:
- 400 Intubations
- 377 RSIs
- 1 awake nasal intubation
- 1 primary surgical airway
These learning points form part of our commitments to governance, excellence and education. All CMAC videos are shared under a Creative Commons Licence: Attribution 2.0 Generic. Please familiarise yourself with the terms of the licence before reusing our videos.
To view these videos, you will need this password: AiRblogVideos
Focus on: Paediatric Intubation
How Deep Is Your Tube?
In this video of a 15kg child we attended following a drowning, there are a couple of really important and useful learning points.
Firstly, the video shows how extensive and troublesome pulmonary oedema can be in these patients. It is certainly something we see commonly; this particular case had involved bystander CPR and even though there was spontaneous respiration by the time our team arrived at the patient – and our pre-oxygenation strategy achieved SpO2 100% – there was copious white frothy fluid in the oropharynx, almost obscuring the cords, and then later seen coming back up the tracheal tube (in the later part of the video). The blade used here with the CMAC is size 4; we have used this blade size successfully in patients as young as 14m of age.
Secondly, the black lines seen just above the cords when the cuff is inflated (image below) might appear to be the lines corresponding to the cuff end of the tube but in fact these are the markings at 10cm of insertion – and in this case, this resulted in a right mainstem intubation.
Arrival CXR from hospital (12:25) is shown with a left sided white-out and clear bronchial tube. This resolves once the tube is pulled back (16:14).
Our Paediatric quick reference cards give an ideal depth of tube insertion by age. This is a handy guide to help avoid this common problem and we recommend confirming tube depth (given as ETT length) at the teeth/lips as soon as practical after intubation.
You can find the Paediatric Emergency Reference cards via the ITIM app.
Video Focus on: Airway Soiling & SALAD
With the case above in mind, it’s helpful to remember that we often deal with significant airway soiling. Our service carries the DuCanto suction catheter and trains for suction assisted laryngoscopy airway decontamination (SALAD).
These two videos show significant soiling.
This video shows significant soiling, presumably from gastric contents, during laryngoscopy.
This video, like the one above, shows significant airway soiling. Suction was used continuously (the SALAD technique) to provide a view in order to secure the airway in difficult circumstances.
Further CMAC Videos:
Very Pale Mucosa in a Hypovolaemic Trauma Patient
This video is notable for the significant pallor in the airway mucosa. This was a trauma patient with considerable hypovolaemia.
Unexpected Difficult View
This patient had an unexpected supraglottic mass, making laryngoscopy difficult. The epiglottis is swollen and surrounded by inflamed and friable tissues.
This patient was intubated successfully by the team and the CT scan image is shown below.
CMAC Size 4 Blade in a 2 Year Old
Another example of the successful use of the CMAC size 4 blade in a small child – in this video the patient is 2 years old.
You can see all the AiR videos here on our Vimeo page.
About the Hamilton we use:
The Hamilton T1: A 7kg transport ventilator with a battery life up to 9 hours, this ventilator allows us to deliver between 2ml and 2000ml of tidal volume, making it suitable for all patients from neonates to adults and bariatric patients. There is the option to set PEEP between 0 to 35cmH2O and an inspiratory flow rate up to 260Lpm. The Hamilton T1 is also able to deliver intelligent NIV with reduced leak and a specific target Fi02. The Fi02 setting range is from 21% to 100% and there is also an integrated nebuliser and high flow options. The circuits are fully disposable, lightweight and easy to carry, and significantly for us- the ventilator can run independent of compressed air if needed.
Most common Vent settings we use and how to set them up:
(S)-CMV: Synchronised Continuous Mandatory Ventilation mode- a pressure- regulated volume controlled mode
SIMV: Synchronized intermittent mandatory ventilation- a volume-controlled mode.
- Power on.
- Complete daily pre-op checks.
- Select mode- S-CMV.
- Select patient adult/ped, height and gender.
- Select Controls tab- adjust RR, I:E, Vt, PEEP and Fi02.
- Press the white cross and return to home screen. -Select the Alarms tab to adjust alarms limits as clinically appropriate.
At Sydney HEMS we tend to default start with a Vt of 6-8ml/kg and a PEEP of 5. The I:E will be 1:2. These are then adjusted to create a patient specific ventilation strategy depending on clinical picture.
NIV: Non-invasive ventilation- CPAP or BPAP.
Complete daily pre-op checks.
Select mode- NIV or ST-NIV.
Select patient adult/ped, height and gender.
Open Controls tab
CPAP: Set PEEP to desired level (EPAP)
BPAP: Set PEEP (EPAP) to desired level. Set pInsp to additional pressure required to generate IPAP
On NIV mode set Psupport to additional pressure required to make desired IPAP ie: IPAP – PEEP
On NIV-ST mode set Pinsp to additional pressure required to make desired IPAP ie: IPAP – PEEP
Select the Alarms tab to adjust alarm limits.
Check for % leak under the values tab- this will help inform how much oxygen you’re likely to need with you for the journey.
Setting the pressures for NIV: Don’t forget to create BiPAP, your pInsp is additive to your PEEP.
What do the alarm patterns mean?
High priority- Red light and 5 beep repeated.
This refers to patient factors such as apnoea, minute ventilation or a Pmax problem, a Circuit disconnection or obstruction, or an oxygen fail.
Medium priority- Yellow light and 3 beeps repeated.
This is highlighting a pressure limitation, Vt or PEEP issue.
Low priority- Yellow light and 2 beeps only.
External power loss.
Physiologically what do the alarms mean?
Minute ventilation: This refers to the amount of gas delivered to the lungs in 1 minute. MVe is usually around 6L and calculated Tidal volume x respiratory rate. If the High MVe alarm is sounding- this is to say the lungs are receiving more than this and the patient is essentially being hyperventilated. Reducing TV or RR may optimise this. However, don’t forget this is just an equation and doesn’t factor in clinical picture and your clinical goal of ventilating in a certain way. Low minute ventilation usually refers to a leak or disconnection in the circuit.
Whilst in S-CMV mode, the ventilation is pressure-regulated and volume-controlled meaning the ventilator is constantly assessing the pressure required to generate the set tidal volume and there can be wide swings in the volume delivered.
pMAX: This is the set maximum pressure limit on the ventilator. On our Hamiltons this will default to **35** and will alarm at pMax-10. If the alarm is sounding- consider what target pMax is appropriate for this patient and if anything may have happened driving a sudden increase in pressure ie. Secretions/occlusion/coughing. If all is clinically well and you just want to adjust the alarm limits, this can be adjusted in the Alarms tab.
fTotal: The total delivered breaths plus patient initiated breaths.
PEEP alarm: If the PEEP is high this suggests a problem with the elasticity of the lungs such as pneumothorax, tension pneumothorax, contusion or pulmonary edema. ARDS, and auto-PEEP caused by “breath stacking can also cause this. Clinically re-assess the patient, consider lung ultrasound and if autoPEEP seems the problem, consider disconnecting and manual release of pressure.
Low/High Vt: The Hamilton auto-calculates Vt according to patient height and ideal body weight at 6ml/kg. High tidal volumes can be associated with barotrauma but if the alarm is saying that a higher volume is being delivered than you requested, consider that this may be patient driven. If you don’t want them breathing spontaneously, consider deeper sedation or paralysis. If Vt is low, consider why. The outcome of a consistent low Vt will be atelectasis and you may need to consider setting a higher PEEP.
Other useful things to know:
Oxygen consumption: In the system tab, the Hamilton T1 will tell you your current oxygen consumption in l/min. This particularly useful in long transfers, patients with high oxygen consumption or patients on NIV where you may need to plan ahead with how much is available or if you need to restock en route.
Auto adjusting alarm limits: In the Alarms tab, below the adjustable bars, there is a button for Auto. This will automatically set all alarm limits around the current monitoring parameter values except Vt and apnea.
The oxygen enrichment key: This is the upwards arrow with 02 written on it and will deliver 100% oxygen for 2 minutes. Pressing it a second time will cancel it. This is useful to oxygenate prior to a disconnection to suction etc.
I:E ratio: Expressed in seconds, this is the amount of time spent in inspiration compared to exhalation during the total respiratory cycle. Example: RR is 12, total cycle time is 5 seconds (60/12 = 5 seconds). If I-time set at 1 second, then 1 second is spent in inspiration, 4 seconds are available for exhalation.
What is ASV? Adaptive Support Ventilation: This is a tool on this ventilator whereby the operator set Mve is maintained but the machine establishes an optimal tidal volume and RR combination to achieve it. In passive patients, this is a volume targeted pressure controlled mode with automatic adjustment of pInsp, RR and I:E ratio. The ventilator calculates MV from ideal body weight at 100ml/kg/min. Fi02 and PEEP still need to be manually entered. There is an argument that ASV is less useful in pre-hospital/retrieval mode and better used in the ICU when patients are starting to wean from the vent.
The inspiratory hold manoeuvre: The inspiratory hold allows us to determine the plateau pressure as a marker of the alveolar pressure in the lungs. This allows us to differentiate the intrinsic PEEP of the lungs and assess the resistance of the airways. To do an inspiratory hold on a T1- The patient needs to be paralysed first. Press and hold the button with the lungs on it to trigger a breath hold, hold it down for 10 seconds (or until you see flow stop on the screen). Press the two arrows facing each other on the top left of the graph screen to freeze the graph. You can then use the wheel to move the cursor backwards and forwards to find a reasonable plateau pressure.
Patient specific ventilation: Key settings we can adjust
ARDS (can consider in trauma)
“Lung protective strategies”:
Controlled oxygen exposure
Low tidal volumes 4-6 ml/kg
Adequate PEEP (rough guide start at weight/10)
Peak pressure < 30 cm H2O (<28cm H2O driving pressure)
Minimise minute ventilation (reduce RR, preserving Vt to maintain MV)
Maximise time for expiration (I:E ration approaching 1:5)
Pressures are reflective of bronchial spasm (therefore in acute episodes, ignore pressure alarms and focus on Vt)
Volume control mode beneficial as improving pathophysiology with treatment will prevent barotrauma reduced bronchospasm.
“Normal” TV (6-8ml/kg)
“Normal PEEP” (5-10cm H2O)
Tend towards Longer I:E ratio’s
Peak pressure <30cm H2O (limiting potential for bullae rupture and pneumothorax)
For more information on how best to use the Hamilton and for increasing your familiarity with it, take time to practice on the machines, explore Hamilton-Medicals online learning modules and use any down time on base to run through them with any of our expert anesthetists on base.
With thanks to Dr Satya Varnasi and Dr David Ransley for their contributions to this article.
Sydney HEMS registrar Dr Jonny Morris takes us through the impact of flight on patients and the things we should consider for patients we are transporting by air.