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Speak Up! How Do We Challenge Consultants When They Can't Intubate?

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Speak Up! How Do We Challenge Consultants When they Can’t Intubate?

Introduction

•An analysis of the case of Elaine Bromiley noted a breakdown of human factors with a particular emphasis on a failure to challenge senior members of the team.[1]
•The aim of our study was to establish methods of challenging used by junior anaesthetists during a fully immersive ‘can’t intubate, can’t ventilate’ scenario.

Methodology

•A fully immersive scenario, with a faculty member playing the role of a consultant anaesthetist. Unable to intubate as part of a rapid sequence induction and then became fixated on intubation.
•Trainee actions were reviewed during the scenario, a semi-structured debrief followed.
•We compared trainees by their level of experience (Core Trainees (CT 1 and 2)

We recorded:

•The number of intubation attempts
•Time to establish an airway (ETCO2) and Lowest SpO2
•Time to first challenge 
•Type of challenge (verbal and non-verbal)
•The type of challenge was graded according to Pian-Smith [2]: 
 

Results

Video Analysis
•13 Core Anaesthetic Trainees participated in our study.
•CT2 Trainees, with an additional year of Anaesthetic training were better at using non-verbal challenges.
•CT2 Trainees used a higher grade of challenging, in particular Crisp Advocacy and Inquiry (Grade 5 Challenge).
•This resulted in a quicker time to challenge, fewer intubation attempts and a faster time to establish an airway with shorter period of desaturation.
 

Analysis of Debrief – Barriers to Challenging

•Did not want to challenge due to hierarchy and fear of jeopardising a relationship.
•Respect for and Trust in consultant.
•Previous negative experiences when challenging seniors.
•Felt inexperienced and doubted their own competencies, knowledge and abilities.
•Trusted the Consultant’s abilities despite violation of DAS failed intubation guidelines. Trainees need to adhere to guidelines, consultants can bend the rules.             
•Candidates expressed that they would be able to challenge their own peers more effectively. 
 

Discussion

•Trainees with an additional year of experience (CT2) challenged more quickly and effectively.
•CT2 used more frequently effective non-verbal challenges, which included putting their hand up to obstruct the consultant, removing the laryngoscope and placing the facemask on the patient to prevent further desaturation.
•CT2 trainees used higher grades of challenging such as crisp Advocacy and Inquiry.
•There are still significant barriers to trainees having the ability to challenge their seniors.
•The main themes to barriers in challenging seniors were due to hierarchy, respect for Consultant’s experience and fear of jeopardising a working relationship.
•Training in effective challenging should be included in the basic curriculum for CT1 trainees and could be further incorporated into fully immersive simulation courses.
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