Remote Resuscitation

Greetings from sunny Cairns, Qld – where I am at the Bedside Critical Care conference.

I had a novel experience the other day.  A remote resuscitation of a critically-injured trauma patient.  Not sure what we should call this…. maybe “VR”for  Virtual Resus, Video Resus, Vicarious resus….

We have recently started using a video interface with some of the remote hospitals in the Kimberley.  As is the norm in my world – not much training – just: “here’s the on button, and you shouldn’t put your coffee cup on top….”

Here is how it works:

– we have 2 high resolution cameras and a video screen in the Resus room of their ED.  They can see my head (lucky punters … ;-))

– at my end a big TV screen with a remote control that allows me to toggle between cameras, rotate and zoom in/out.

– the cameras are very good – I can read handwriting, look at the monitor, even read an ABG printout on the desktop, even do a remote-controlled FAST exam!

– the microphones are voice-activated – so I can speak and hear the conversation as if I were in the room.

Awesome set up – however, it is early days and it is fair to say that there are plenty of logistics to work out with the way the team works.  Anyway I thought I would spend a few lines to reflect on what we learned from this experience.  I have done a bit of training around crisis management and communication in the Resus Room – and I think that this experience has really highlighted for me how crucial the basics of communication and logistics are when it comes to remote Resuscitation!

Picture this:

– You have time-critical trauma patient with compromise to A, and maybe B and C and definitely D.

– The “ground team” are doctors and nurses that you have never met, you don’t know their names – you have spoken on the phone in the past and have a vague idea of their skills and experience

– none have specific training or recent experience in critical care, airway management – but are all EMST / ATLS trauma course graduates

– The room is supposedly set-up in a standardised fashion – but the exact location of all the gear is unclear.

– The pharmacy is standardised – but the staff are occasional users of the common resus drugs

Now if I were on the ground and I started getting questions and suggestions from a “head on a screen” I think I would find it reasonably odd, maybe a little irritating possibly downright infuriating!  So the allocation of a “team Leader” role to somebody hundreds of kilometers away has got to be done in a thoughtful manner.  Usually the team leader knows the layout, knows the teams skills and has 360 degree vision of the environment – but this is not the case in our setup….

Tim Leeuwenberg recently drew my attention to the “Blindfolded Resus Leader” concept used in Sim training to enhance the use of verbal communication in a team environment.  I have tried it out in a Sim session – but I found that using a Video system to run a resus not dissimilar to what I imagine a blind-folded leader to experience.  It is amazing how much we rely on non-verbal cues!

Lessons I learned today:

–  Using “Names” to identify the team member you are addressing is vital.  As a talking head you cannot make eye-contact or ensure your target is looking and listening – so you need to be constantly using names, confirming attention, giving instruction and then getting confirmation once the task is completed or instruction acknowledged.  You cannot rely on non-verbal confirmation, and often you cannot see the task you have assigned being actually done as the team might be obscuring your view – so “closing the loop” verbally is crucial.

–  Having clear.y defined roles in the team is great.  And when you are working with an unfamiliar team – then each team member needs to be assigned to a role such that they know what their next task is.  This cannot really be done on the fly – this part of any resus /critical incident requires some degree of pre-planning and practice.  Nurses are good at this, doctors; not so much, in my experience.

–  You also need your team to start their sentences with your name – “Casey”… “Yes”  …  as without any directional verbal input or eye contact it is impossible to know if a sentence is aimed at you or another team member.  I know that the military and other agencies have been doing this for years, especially with radio communication – and this is why!  We all know that it is good practice to assign tasks to an individual rather than to “Somebody”.  As “Somebody” invariably delegates it to “Nobody” and quite frankly “nobody” has serious performance issues!

–  Being able to zoom and twist the cameras is cool – but a bit cumbersome, when the adrenaline is running high it is easier to maintain a  wider perspective on the room and ask the team to yell out the small print.  Once the dust was settled a bit it was possible to zoom in on the Ventilator and the monitor to check numbers etc, but hard to do when you are task saturated in the initial crazy moments of a resus.  In reality it takes 5 – 10 seconds to adjust camera settings, and this seems like a week when you really wan to know – is there CO2?, what is the BP now?, what is the pressure on the vent that just alarmed? …

– Situational awareness is tough.  Noticing the small things can be hard when you have by definition “tunnel vision” down the camera. So I needed to rely on the team to yell out these numbers and information.  This is a good thing, I think it keeps the team on the same page as the case progresses to the more mundane tasks.  We all remain on alert as there is a constant banter about the obs and so forth.

– Checklists!  I know – they seem painful when you are a senior, experienced clinician who does RSI etc in their sleep.  But in this situation they are absolutely invaluable.

In a crisis you need to be able to give team members a set list of tasks and ask them to focus just on those and ignore the noise in the situation.  Prime example is prepping for intubation – give a team member a checklist, read it aloud and ask the team to confirm as you go.  In a way drip sheets and trauma cards are the same thing – they are standardised cues for inexperienced or occasional team members to utilise.  As a virtual team leader it is just too much info for one to transfer to an individual – it is much easier to say:” pick up the Norad infusion card and follow the instructions”  than to actually talk a nurse through the whole drawing up process whilst all the rest of the team try and do their tasks.

Would love to hear if anyone out there is using a similar set-up and if there are any pearls of practical wisdom to share.

Casey

 

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