Vassiliadis inspires with his trajectory from novice to teacher of airway skills and checklist applications.

1. Courage Under Fire
Dr John Vassiliadis MBBS FACEM
Senior Staff Specialist Emergency Medicine, Royal North Shore Hospital
Deputy Director, Simulation, Sydney Clinical Skills and Simulation Centre
Senior Clinical Lecturer, Sydney Medical School
LCDR RANR

2. Road Map
•
Why are we not perfect and make the correct decisions
every time?
•
Are checklists useful?
•
Examples of checklists
•
What makes a good checklist?
•
RNSH airway registry and lessons learnt
•
RNSH Airway checklist
•
Take Home points and Call to Arms

3. Acknowledgements And Disclaimer
•
Drs Toby Fogg and John Kennedy
•
Views expressed are solely my own
•
No financial interests to declare

4. Why do iatrogenic errors occur?
Assumption: “Do no harm”
1. Beyond our control
o
o
We do not have the knowledge of how to diagnose or treat
2. Swiss Cheese Model1
Combination of organizational, supervision, unsafe act and the
precondition for unsafe acts
2. Under our control
o
o
Training and experience issue – junior, inexperienced or ineptitude
Human Factors
1. Reason, J. Human error: models and management. BMJ 320(7237): 768-770

5. Factors that make decision making in a
critical care environment difficult?
•
Us
•
o
Patient factors
•
o
Limited history, emergent conditions, sick,
Institution
•
o
Hungry, Angry, Late, Tired
Time pressures to move patients, number of staff,
supervision
Number of decisions made in a shift

6. What/Who Can We Turn To?

7. Advanced Life Support
for Adults
Checklists can Help!!
Start CPR
During CPR
30 compressions : 2 breaths
Minimise Interruptions
Airway adjuncts (LMA / ETT)
Oxygen
Waveform capnography
IV / IO access
Plan actions before interrupting compressions
(e.g. charge manual defibrillator)
Drugs
Shockable
* Adrenaline 1 mg after 2nd shock
(then every 2nd loop)
* Amiodarone 300 mg after 3rd shock
Non Shockable
* Adrenaline 1 mg immediately
(then every 2nd loop)
Attach
Defibrillator / Monitor
Assess
Rhythm
Consider and Correct
CPR
for 2 minutes
Hypoxia
Hypovolaemia
Hyper / hypokalaemia / metabolic disorders
Hypothermia / hyperthermia
Tension pneumothorax
Tamponade
Toxins
Thrombosis (pulmonary / coronary)
Post Resuscitation Care
Re-evaluate ABCDE
12 lead ECG
Treat precipitating causes
Re-evaluate oxygenation and ventilation
Temperature control (cool)

13. What Makes A Good
Checklist
•
Clear, precise, simple, short
•
Not meant to explain how to do a procedure, it is
memory aid, NOT a comprehensive HOW TO
GUIDE
•
Reminder of critical and important steps
•
Should be a Read and Do
•
Willing to update and improve

14. Weakness of Checklists
•
People must be willing to use them
•
“Buy in” by teams
•
You must have a defined time to use the checklist and
this must be clear to the team
•
Defined person to initiate, “champions” or “zealots”
•
Checklists will not solve every problem, so team must
be flexible enough to stop an communicate and work
through the problem

15. RNSH airway registry

16. www.airwayregistry.org.au

17. www.airwayregistry.org.au

18. What we learnt
www.airwayregistry.org.au
•
297 intubations in 18 months - equates to 4 per week
•
21% between 24:00 and 08:00
•
30% pt were traumas, commonest indication was
overdose (15% of all pts)
•
Average age 52
•
Male : female ratio 1.7:1
•
Only 3% of pts had an estimated wt. above 130kgs

19. What we learnt
www.airwayregistry.org.au
•
Specialists were team leaders in 70%
•
Registrars/SRMOs had 89% of first looks
•
Our first pass success rate was 81%
•
Only 10 patients (3.3%) needed 3 or more attempts
•
Difficult laryngoscopy (Cormack and Lehane III/IV)
encountered in 23% patients on first attempt. This
was not associated with the intubator’s grade or
airway experience, or the patients condition

20. What we learnt
•
www.airwayregistry.org.au
Those who have limited experience at laryngoscopy,
i.e. SRMOs who haven't done anesthetics, have only a
58% first pass success rate. The data also shows that a
prior experience of >10 intubations (a novice was
arbitrarily defined as <10 intubations) increases the
odds of success on the first attempt by more than four
fold compared to a prior experience of <10 (OR:
4.36; 95% CI: 1.81-10.52; P=0.001).

21. What we learnt
www.airwayregistry.org.au
o
30% of all 345 attempts were done naked: without the
aid of bougie or stylet
o
Complications occurred in 28% of patients, with a
particularly high rate of desaturation (10%)

22. ED!Intubation!Checklist!!
IVI/Drugs
Pat ient
Team
o Fluids connected, runs easily?
o Spare IVC?
o Monitor: ECG, BP, SaO2.
o In hours, ED Senior Dr aware of RSI?
o Pre-oxygenation optimal?
o Add nasal prongs or NIV
o Out-of-hours, if difficulty anticipated,
anaesthetics contacted?
o RSI drugs drawn up, doses chosen?
o Post-intubation anaesthesia plan drugs drawn up?
o Patient position optimal?
Equipment
o All members introduced by name &
role and each briefed in turn by TL
o Patient haemodynamics optimal?
o Fluid bolus?
o
Pressor?
o Difficult intubation plan briefed?
o Does it look like it might be difficult:
o Difficult airway trolley at hand?
o Difficult BVM?
o Difficult laryngoscopy?
o Anticipated problems – does anyone
have questions or concerns?
o Difficult supraglottic airway?
o Difficult cricothyroidotomy?
o Suction working?
o BVM with ETCO2 connected?
o OPA and NPA available?
o 2 x laryngoscopes working? Correct
blade size?
o Tubes chosen, cuff tested
o Bougie or stylet in tube?
o Tube tie or tapes ready?
o Ventilator circuit attached?
o LMA sized & available?
o Surgical airway equipment available?
Version!1.3!
Developed!by!T!Fogg,!J!Kennedy!and!J!Vassiliadis,!RNSH!ED!25/ 10/ 2012

23. Take Home Points
•
No one is perfect! We are all human!
•
We work in a high pressured high stakes environment
•
Checklists can help if used properly, review your
work practices and challenge what you do!!!