Case report:

Case 1: “Patient admitted to ED following 3/7 hx of sore throat, identified by SpR as being acutely unwell, moved to monitoring for closer observation, pt had audible stridor and low sats. Dr prescribed all necessary medications and these were given promptly by nursing staff. Medics requested anaesthetic review alongside ENT review, ENT reg attended department from [nearby tertiary centre, 10 minutes away by road] and examined and plan was discussed with HDU at [tertiary centre] for transfer when stable and suitable to do so. Nursing staff voiced concerns of nursing pt in monitoring bay and that resus was more appropriate which was dismissed by anaesthetics on more than one occasion. As further discussions took place regarding where pt should go pt deteriorated significantly and airway was at significant risk of being lost, joint decision between anaesthetics and ENT for immediate transfer to theatre for intubation. Grab bag taken from resus for transfer with ENT calling theatres to be ready and have emergency trachy kit available - nursing staff advised theatre not ready but 'should be by the time we get there'. Transfer taken despite queries from nursing staff and SpR in ED. On arrival to theatre no staff available and theatre not prepped ready for procedure - pt began to deteriorate further team were advised by SN that sats were now dropping into the 50's and was there anything she could do to help, she was advised to be prepared to undertake CPR - pt subsequently arrested. CPR given and ROSC achieved. Pt now intubated on ITU.”

Commentary:

There is much about this story that is troubling, yet it is easy to see how the situation evolved. Dealing with acute airway emergencies such as this away from the tertiary centre can be very challenging and can stretch staff and systems that are not used to it. Senior medical and nursing staff should be directly involved in such cases. The clinical situation can evolve quickly and can easily become overwhelming. Experience and extra pairs of hands always help.

Case reports:

Case 2: “Patient presented with gross lower facial and neck swelling - Presented as a ‘blue call’ to ED resus. Initial impression felt to be Ludwig’s angina. IV Abx and fluids were given. Initial lactic acidosis was noted, however, patient was clinically not shocked. Patient was stable from an airway and respiratory point of view. Discussion with max-facs consultant overnight - Advice for CT scan of the head and neck as well as review of the airway in case this needed securing. Discussed with night ITU SpR, and agreed that as patient was stable no need for review, but did take the details.  CT scan for head and neck with contrast protocolled by teleradiology service querying Ludwig's angina after discussion with max-facs and ITU and form dropped off to CT. Radiographer aware patient was a resus patient with facial and neck swelling, but stated they would call resus to bring the patient. After 1 hour, no call had been received and CT stated there was a high volume of patients in CT from other areas in ED. Agreed to bring patient with doctor escort (myself). Arrived in CT, and patient was stable. CT radiographer wanted to confirm exactly what scan to perform so long delay getting through to teleradiology service while patient was in CT corridor. Patient was generally sleeping with no respiratory distress or oxygen requirement. Scan performed… Patient noted to now have some soft stridor following the CT scan.  Patient brought back to resus, and ITU bleeped to inform them of the stridor and requested review in resus. Adrenaline nebs and dexamethasone given.  Stridor progressively worsened, becoming more harsh in nature. ITU bleeped again as still had not come to ED. Resus ED team began to prepare for intubation, difficult airway trolley moved towards patient, anaesthetic and muscle relaxant drugs brought to patient's bed space. I began to set up for an arterial line to aid intubation.  Patient was reporting some difficulty in breathing, but was able to still talk to me. Patient was sat up at 90 degrees with an ongoing adrenaline nebuliser, saturating 92-94%, but was tachypnoeic.   ITU SpR arrived in resus, agreed this patient needed intubation and bleeped Anaesthetic SpR. Phone call from anaesthetic SpR answered by myself, and explained that there was a patient I thought had Ludwig's angina that we were preparing to intubate and asked them to come down. Agreed to come to Resus, and we asked them to contact the ODP/anaesthetic nurse so they could both help us.  On returning to the patient's bed space, some attempt to pre-oxygenate the patient with Water's circuit was made, but the patient started to become more agitated upright in the 45 degree position. ITU SpR asked us to get rocuronium, propofol and midazolam (rocuronium vial was already on the drugs trolley unopened).  The ITU SpR asked for a Mac 4 laryngoscope and bougie at this point. (I assumed to prepare for intubation).   The patient was then laid flat (while awake and moving his head from side to side) by the ITU SpR, and while flat was asked to open his mouth. Laryngoscope inserted into mouth, and patient started coughing. I challenged the ITU SpR about this and he stated he was simply having a look, and shouted to give drugs (we assumed he meant anaesthetic agents and muscle relaxants, but no doses were specified). These drugs had not been drawn up. The current monitoring on the patient at this point were saturations, 3 lead ECG and non-invasive blood pressure, and the patient was not at this time being pre-oxygenated. The members of the team present in the cubicle were the ITU SpR, 2-3 resus ED nurses and myself. There was no mention of an intubation plan either, and roles had not been allocated. There was definitely no mention of an airway assistant.  While I was drawing up propofol and rocuronium, I turned around to see the ITU SpR inserting the laryngoscope in the patient's mouth - when challenged again, he asked had the drugs…”

Commentary:

The report is truncated at this point by the text limits of the reporting system, but it is recorded elsewhere that the patient died. What has been recorded has some alarming features. There were clearly some communication issues and lack of planning in an out of theatre environment. This is a rare condition and recognition and response is always a challenge. However, there are some basics to be adhered to such as basic minimum monitoring, adequate preparation of drugs and equipment, and adherence to recognised airway management protocols.

Case report:

Case 3: “Pt critically unwell in resus requiring intubation. Anaesthetics doctor attended. Intubation attempted without optimisation of patient (SBP 63 at time of first attempt), without monitoring in place; initial 2 attempts with no sats for several mins due to poor perfusion whilst being trouble shot, No ETCO2 for approx 4-5 mins despite raising the concern and asking if they would like it to be put into the circuit. Multiple intubations attempts (5 in total) first 3 with limited planning (no suction available, no pre-oxygenation, no Mapleson-c or BVM or oxygen on patient), multiple different items requested in haphazard manner requiring multiple runners. ED requested ICU to assist during 3rd attempt, igel inserted with EtCO2 (no trace noted and challenged by ICU and ED) Planned VL by ICU and on 2nd VL look airway secured.”

Commentary:

It is hoped and expected that the submission of this organisational report will have led to a robust examination of the facts with a suitable response.

Intubation in the emergency department is often a high stakes procedure, often in an unfamiliar location with unfamiliar staff. It is vital that only sufficiently experienced and appropriately trained anaesthetic staff undertake this procedure. It is a situation where it is hard to defend the failure to use a cognitive aid and/or checklist. The Royal College of Emergency Medicine advocates for the use of the rapid sequence induction checklist of the Royal College of Anaesthetists and Faculty of Intensive Care Medicine (FICM) [1] although there is now a more recent version from FICM and the Intensive Care Society [2]. Individual organisations should adopt a version that suits their exact set up.

All of these cases illustrate issues around speaking up during critical incidents. There is room for all clinicians to learn about using specific communication tools for graded assertiveness (PACE or CUSS for example). One side is about learning to be assertive, but the counterpoint is about learning to hear and receive the view of the other person. Finally, it is important for organisations and individuals to create a culture where staff feel able to speak up.

References:

[1] Rapid Sequence Inductions in the Emergency Department. Royal College of Emergency Medicine, 2021

[2] Intubation Safety Checklist. Intensive Care Society, 2022