Hats off to retrieval

OK, interesting twitter exchange at the end of the month. Although initially a sceptic, I have been converted into using Twitter into a valuable tool. Think of Twitter as a tool to have a corridor conversation – where the best learning happens – but with colleagues around the world. Just today had three fascinating discussions

First critique and comment on ‘The Checklist Manifesto’ from colleagues in the UK (Thanks @EdValentine2) via doctors.net.uk. This is part of a valuable campaign of attrition before debating Minh le Cong a SMACCGOLD on ‘real airway doctors don’t need checklists‘. Minh’s going down and the trash talk beforehand is heating up…

Then an exchange with other emergency & rural doctors on the notion that “all over 50yos with back pain have AAA until proven otherwise”. Given that I’ll see 15 or so new onset >50 yo people with back pain a week, this can make rule in/rule out a challenge. Thank heaven for bedside ultrasound. Lead nicely into a discussion on investigating back pain, X-rayvs CT and MRI, with all the usual traps fro young players AND the lack of access to MRI in many places.

Finally (and still ongoing as I blog), an exchange with Minh (of course), Jo Deverill, Rob Simpson, Chris Cole and Nat Hincksman on retrieval dogma. Discussion started off on the topic of WHEN to handover and to whom – to just the team leader vs to the entire team, and when to do it. Lead into a more local specific discussion on some of the ‘no nos’ that retrieval teams encounter.

All of this plying out against sad news of a winching death with Air Ambulance Victoria. Retrieval services do a flipping fantastic job and I think rural clinicians as a whole are immensely grateful for the service. I’m relaly keen to see what rural doctos can do to help the retrieval service, and vice versa. There’s a LOT in common, but it requires a focus to raise the bar in some rural hospitals. Following on from Mr EM-CRIT (Scott Weingart’s) mantra of ‘bringing upstairs care, downstairs’ a few of us in rural medicine are trying to bring ‘quality care, out there’ – via FOAMed. I am looking forward to speaking more on this in the rural stream at SMACCGOLD next year.

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I’ve posted about this before, but medSTAR in particular have really raised the bar in SA – no more faffing around with multiple phone calls, negotiating beds. Just a one stop phone line and (generally) sensible advice. In 2011 I was working in rural NSW in a tertiary centre, and trying to organise a transfer from our ICU or ED to Sydney involved numerous calls, shifting of responsibility and general frustration – I often wished I was back in South Australia!

So some common themes as a rural clinician to make it EASIER for the retrieval service, wherever you are.

(i) sort out your patient. Make sure they’re plumbed up properly and that you’ve followed any advice given by retrieval. Blogged about this a few months back – see ‘still a long way to go

(ii) actually BE THERE when the retrieval team arrive, in order to give a handover (excused if dealing with another sickie, but kind of hard to justify otherwise). Minh even reckons one should self-catheterise, to avoid loo breaks. I HOPE he was kidding

(iii) have a structured handover. I don’t think anyone disagrees about structure – MIST, ISBAR, A-O (transfer checklist). They are all useful.

However there was debate about WHEN to handover.

I’m in the same camp as Rob Simpson and Jo Deverill and (I think) medSTAR…my preference is (unless the patient is in or about to arrest) pause for 45 seconds and take/give a handover. Ideally the WHOLE team should STFU and listen. Theres nothing worse than a TL to TL handover happening in a cacophany of BPs being taken, obs recorded and ventilators switched over…then a member of the receiving team asking the same questions that were given at handover.

Sure, in a time critical scenario it makes sense to parallel process – treat and package and exchange info – but really, is a 45 s handover going to make THAT much difference?

Rob reckons he uses his ice hockey experience to ‘hip swing’ people out of the way. I am blessed with RNs who are also excellent net-ballers and used to blocking.

You can argue about when to handover – on the existing bed/trolley or when on the receiving team’s bed/trolley. Personally I’d rather handover first so everyone knows the little old lady has a fractured hip & multiple myeloma  rather than find that out after she’s been transferred in agony!

Which leads into my other bugbear – do you use 1-2-3 or ready-brace-action? I KNOW that a broef before is useful, but I’ve seen too many people get ‘briefed’ on 1-2-3 then go and do their own thing (if you’ve ever seen the ‘bomb on toilet’ scene from Lethal Weapon 2, you’ll know what I mean). I use ready-brace-roll in theatre as team training for resus. No ambiguity there.

Lethal-Weapon-Toilet-Bomb
Go on 3? Or 1-2-3 then GO?

So – the rule is – no entry to the resus bay until a handover has been performed. But for heaven’s sake, if you ARE a country doc and you’ve called retrieval – please be in the hospital to handover!

Natalie Hincskman summarised it well from her perspective with the retrieval service :

– land and listen

– pause and plan, then

– respond with right resus

Do YOU have any bugbears or dogma from a transfer perspective?

 

2 Comments

  1. Great post Tim.

    Having been at ARV (and working solo) for just over a week now I have seen all sorts of handovers. I have to say that the small rural hospitals I go to in Victoria have been uniformly excellent. Most of the handovers seem to be nurse-led and it makes more sense when they have spent eight hours with a patient when the doctor may have never set eyes on them. Often this occurs in conjunction with shift changes it seems and information gets lost.

    Once the patient has been (carefully) packaged and transported across the state it is often a different matter. Docs seem to want the handover as quickly as possible so that they can get on with whatever they were doing whereas the nurses want the patient comfortable, well sedated and ventilating/oxygenating happily before handover. I like to make the team aware of anything relevent to the move e.g inotrope dependence, bronchospasm, dodgy lines, infection risk before moving them over. Then I can give one concise handover to both nurse and doctor at the same time before picking up all my gear and heading home.

    Reply
    • Thanks Andrew, it is so good to hear that you’re happy with standard out there – many do it very very well – but some don’t (see the post ‘still a long way to go’)

      Stable patient, secondary retrieval – makes sense for whoever knows the patient best to HO. In fact, makes sense in whatever situation for person with knowledge/skills to do the job – thats why I love the retrieval practitioner role medSTAR have been using for a few years.

      Unstable patient – the doctor on charge should be there, not elsewhere. Hard to argue against that.

      Key think is that essential info is communicated. I reckon best done by a nominated TL of whatever ilk, handing over to the receiving team, preferably before moved from one bed to another, and handover is both structured and to the whole team. Bit like sterile cockpit. One voice only. CRM innit?

      Leads me on to another thing – does anyone practice the ‘sterile cockpit’ (or in the country, STFU) approach during key procedures, particularly Intubation? Sometimes I wish everyone would STFU in theatre when I am sending patient off to sleep and intubating…

      Reply

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