All posts by anzcaadam

Version Guide

V1. Oct 15 -Original document

V2. Feb 17 – Multiple changes. To numerous to list here but can be found in this list here.

v2.1 Oct 17 – Minor additions mostly to do with adding in more paeds emergency information. 1 major correction on infraglottic rescue: 2nd breath via cannula should be 500ml not 250ml

v2.2 Nov 17 – Improvements to formulary terminology & dosing as well as some phrasing used throughout the book.

Major changes: CICO supraglottic page based on the Vortex Approach. Changes to adult and paeds arrest pages to better describe what to do with different airway strategies.

v2.3 Jan 18 – Added severe bronchospasm on 28d Low EtCO2 as a cause for no EtCO2.

v2.4 Apr 18 – Changes to bronchospasm. Decr max pressures, removed “listed in priority order”, changed LV failure to pulmonary oedema, improved suggestions around ventilatory strategies. Changes to low EtCO2 page: reordered differential diagnosis lists. Clarification on hyperkalaemia page on dosing of 10 units of insulin in mls.

v2.5 May 18 – Changed hyperkalaemia page to dosing in mls & undiluted insulin. Correction to instruction page formating. Slight correction on eclampsia magnesium regimes for local hospitals

v2.6 June 18 – Updates to Vortex airway page. (Thank you Dr Chrimes for your suggestions)

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How I Made It

PRINTED VERSION

While the digital format is useful in terms of wider education, and personal reference I wouldn’t advocate using it in a crisis. Hence the need for a physical version. No unlocking the phone, tapping on your pdf app, scrolling and zooming required. The book should be in a known, consistent place in every Anaesthetic Location.

PRODUCTION

As part of producing the 2nd version of this manual I have investigated ways to speed production up. It still requires some arts and crafts.

– I have experimented with some colour laser printable, waterproof tear resistant plastic paper. Depending on where you buy the paper this can range from 70c to 150c/page. I would recommend using paper as heavy as you can find. >150gsm is ideal.

– Then print double sided colour on all pages except first 2 pages of both books. I relaxed the need for borderless printing and printed with a border (shrink to 96% of fullsize to account for the full page .pdf books)

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– Cut the tabs out on these sheets with a guillotine. I tried to angle the cut to further protect the tabs. There is no need to laminate these pages now.

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– Print the first 2 pages of each book on standard A4. Laminate these only. Make sure to leave a big clear border on the right hand side. This will protect the tabs when the book is closed

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– Collate the book into its topsy turvy design

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– Wire bind the book – then you’re done

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The advantages of this method are that: quick to print on hospital colour laser printers, no need to cut the tabs then laminate then cut the tabs again, the book is thinner, the plastic paper prints really clearly and nicely. Most importantly it is much faster!

IMPLEMENTATION

– I tied some fine bore plastic infusion tubing around the top three rings to allow the book to be hung. Another option is a zip tie

– Finally: I superglued hooks to each Anaesthetic cart, and printed some stickers to place under the hooks (to alert people to where the handbook is meant to be hung & thus missing if not hung there).

DIGITAL VERSION

This involved less steps but unfortunately still time consuming:

– Firstly: On the Mac its pretty easy to convert .pages files into .pdfs by ‘printing’ pages files into pdfs
– Then: Collate all the individual pdfs into on document by dragging them into the thumbnails on Preview. Then ‘print’ them all into one pdf document
– Next to enhance the pdf:  I bought a MAC program called PDFpen9. Not cheap but it is quick to go through and add internal links to all pages.

This multi-step process isn’t entirely perfect unfortunately. It means every time i make a change on a pages file, i need to reprint the pdf, re-collate the individual pdfs into one book, then load it in pdfpen9  and re-add all the links again. Pretty painful unfortunately. In the last year apples pdf kit has also broken it’s relationship with clickable links in pdfs. I can find no work around except to not open the digitial file in preview/ibooks or anything apple. If you do, and click a link that link will be permanently broken. Instead i recommend using any other pdf viewer eg adobe, goodreader etc.

Crisis Handbook Localisation

Finished Localised Versions

Hutt Hospital

Digital version v2.6 with clickable links (Apple pdf viewers eg preview or iBooks will break the links – use another pdf viewer)

Print Version: Emergency Book v2.6 ; Diagnosing Problems Book v2.6

Wellington Hospital (Many thanks to Raj Palepu for localisation efforts)

Digital version v2.6 with clickable links (Apple pdf viewers eg preview or iBooks will break the links – use another pdf viewer)

Print Version: Emergency Book v2.6 ; Diagnosing Problems Book v2.6

Localisation Instructions

I feel strongly that a crisis manual needs to be adapted for local use. Only in this way it can be of maximum benefit in the heat of a crisis. For example, what is blood bank’s number, do you have an anaphylaxis box and so on….

In this regard i added a telephone directory page to version 2. You could write on this manually or add in the numbers digitally. I still think having relevent info & numbers on the relevant pages is better though.

In order to help a localisation process I’ve made a guide. Please read it fully, follow the rules and thus make me happy.

View it here.

If you’d like the source files in Apple Pages format for editing then please email me: adamhollingworth@icloud.com

Any feedback is always appreciated.

Video Demonstrations

We videoed some simulation to demonstrate the use of the manual in theatre.

The idea was to focus on how the manual can be useful in different situations. The specific focus was to show how useful it is to incorporate a ‘reader’ role into the crisis team.

The first simulation involved a paediatric arrest. The manual & the reader could be very helpful with:

  • adherence to critical tasks
  • equipment calculations
  • drug calculations
  • reversible steps – specific to children/theatre
  • communication & avoidance of task fixation

Here it is…..

The second simulation involved unexpected high airway pressures. It was designed to show the second half of the manual which is designed to help diagnose/prevent problems before they become a crisis. The manual & the reader could be very helpful with:

  • frequency gambling to the problem
  • systematic approach to diagnosing the problem
  • full list of potential causes to consider
  • communication & avoidance of task fixation

Here it is….

Thanks for all that helped make the simulation happen!

Design Choices & My Opinions

I’ve come to develop some strong opinions on the utility of cognitive aids in emergencies. Most of this is evidence based rather than my internal crazy:

 

  • Having a ‘reader’ is vital. This dictated the design of the aid. It should have a linear flow to allow non-anaesthetists to read it easily. Flow charts are hard/impossible to describe across a room.
  • Algorithms are designed to be used as a reference and are not that useful in a crisis. They are also generally not localised to theatre or anaesthetics. 
  • People must be familiar with an aid before needing to use it in a crisis. This also dictates the benefit/need of a universal design theme for an aid in a crisis. There is great advantage in every page being laid out the same. People know how the aid works, and thus how to use it. Learn the theme of one page, learn them all
  • Drug calculations in an emergency are littered with error. Infusion calculations are an absolute disaster. It is imperative these tasks are ‘offload-able’ in a crisis. Thus these should be laid out as for a non-anaesthetist to do.
  • Main priorities should be spelled out early i.e. first!

 

Other things suggested by the experts in the literature:

  • Content should be derived from best practise guidelines
  • It must be localised and simple. 
  • it must assist other team members
  • it should be reviewed by local experts and updated as guidelines changed. 

These opinions dictated the design choices in this manual:

  • Its bright & bold. So use it.
  • Instruction pages at the front to guide people on how to use the book & best practise in a crisis.
  • Encouragement to utilise the reader role
  • In fact the book has been designed around the reader role:
    • List based design. Read from top to bottom
    • Words & phrases which are easy to read & hopefully non-doctors can understand
    • No algorithms found in the book
  • Drug calculations pre done based on 70kg person. Infusions are kept simple by stating what to put in what and dose range in mls/hr to run at (to enable you to offload setup to a non-anaesthetist if required)
  • Quick reference index page & tabs for quick navigation
  • Same design on each page. Red section = emergency tasks. Yellow section = thinking tasks or further info. Green section = drug doses or equipment calculations
  • Lots of visual aids – bolded words, highlighted decision points, all drugs in bold green
  • Comprehensive drug formulary for adults & children

 

And much more….

Evidence

There’s lots of studies out there investigating the use of cognitive aids in crises. The following are a mere smattering of the ones i found most interesting & useful when launching into this project….

 

NEJM. Simulation Based Trial of Surgical Crisis Checklists.  Without checklists 23% of critical steps missed in crises. With checklist only 6%.

 

Anest & Analgesia. Use of Cognitive Aids in a Simulated Crisis. Showed improvement in management of MH with checklists. Especially if the checklists were read out loud.

 

Reg Anes & Pain. Editorial: Is it Time to Use Checklists for Anaesthesia Emergencies. Commentary about checklist in LAST. Participants without a checklist completed 8/21 tasks, with a checklist 16/21.

 

J Amer Col Surgeons. Crisis Checklist for the Operating Room: Development & Pilot Testing. Small study piloting their new checklists. Showed x6 reduction in adherence to critical tasks with checklists.

 

Anes & Anal. The Use of Cognitive Aids During Emergencies in Anaesthesia: A Review of the Literature. A good overview of the good & bad about using an aid in a crisis.

 

Can J Anes. Cardiac arrest in the OR: How are our ACLS skills? A study demonstrating how bad humans are in a crisis at adhering to critical tasks/protocols without help.

 

Sim Healthcare. Does Every Code Need a ‘Reader?’ Improvement of Rare Event Management with a Cognitive Aid ‘Reader’ During a Simulated Emergency. A great study demonstrating the problems with using a manual. But a way to overcome them…Use a reader!!