Here is our latest in situ simulation write-up. This was one was done on the paediatric ward. Included is human factors feedback from our aviation colleagues who were present for the sim.

SCENARIO

• 6 month old baby on paediatric ward
• Becoming increasingly drowsy, ward paediatric doctor alerted by nursing staff
• Fulminant sepsis secondary to chest infection
• x2 failed IV cannulations, IO performed

CLINICAL FEEDBACK FROM DR. MUMTAZ MOONCEY (PAEDS TRAINEE)

Positives

• Rapid diagnosis of sepsis
• Intravenous antibiotics and fluids commenced early
• Decision-making in keeping with APLS/EPALS guidance
• Aware of appropriate PPE precautions, and instructed team to ‘don’ accordingly

Clinical learning points

• A paediatric crash call could have been put out earlier
• Try not leave the patient alone (unless absolutely necessary)
• A patient needing fluid boluses of 40ml/kg or more should be considered for intubation due to risk of pulmonary oedema in the septic child
• Consider need for vasopressor/ionotropic support early (can always call CATS for advice if unsure)

HUMAN FACTORS FEEDBACK FROM OUR PILOT COLLEAGUES

Communication

Positives
Lead created an open communication culture by empowering team members to speak up during the scenario. Team members spoke confidently but without being overbearing towards the leads command style.

Pace was good throughout the scenario, despite the situation becoming more intense (IO drill).

Excellent active listening by the team member tasked with looking after the distressed parent.

Areas for improvement
Initially, no clear call for help by the lead resulting in a couple of uncomfortable moments with the parent and child left alone. Consider calling for help immediately, then give yourself a moment to take in your surroundings. Perhaps a slow, deliberate donning of PPE would be enough of a ‘breather’ before you announce “I am the lead!”. Then you can begin task allocation.

Readback/closed loop communication was not evident with requests for 20ml/kg of fluids not confirmed on more than one occasion. The risk of misunderstanding is greater with face masks being worn.

Body language and position of the lead made communication difficult at times. Consider standing at the end of the bed sooner and avoid having your back to colleagues, especially those taking requests for fluids/medication.

Analysis (with aviation crossovers)
Effective communication has a huge impact on flight safety. As a commander, establishing good comms with your crew begins at the very start of the day in the briefing room. We use this time to introduce ourselves, empower our colleagues, and project our command style. We call this the Golden 5 minutes. Once the clinical lead had the team around them, it might have been nice to position at the end of the bed and give a quick overview of the situation, asking team members what they feel comfortable helping with – this could have been your ‘Golden 5’. 

To slow down the initial startle of the sick baby, consider calmly and deliberately putting on your face mask. Use these short gaps to think about your next move, a few seconds at the start will make a huge difference over the course of the emergency. If we have a decompression in flight, we would announce “Loss of cabin pressure” before slowly donning oxygen masks, using this time to carefully think about our memory actions that follow.

A lack of readback/closed-loop communication is a common theme during our observations in the sims. “20 ml/kg please” “ok!”. To put it simply, every single important switch, every radio transmission (and we make a lot) and every change to the aircraft flightpath must be confirmed and read back by our colleague in the flight deck and/or air traffic control. In this case, it would have been great to have seen: “20 ml/kg please” “You would like 20ml/kg?” “Yes”.

Workload Management

Positives
The lead was active in many aspects of the treatment with a style of ‘leading by good example’ (e.g. carrying out the IO procedure accurately).

It was quickly recognised that the parent was distressed. The lead preemptively allocated someone to accompany them. As the child’s health deteriorated, the lead then reactively asked the parent to be removed from the bedside to reduce distraction. This was excellent task allocation.

Despite distractions, the lead’s focus never drifted from the primary health of the child – priorities such as airway access were stated and allocated to team members. A call was made to the anaesthetist.

Assisting doctor recognised the intensity of the situation and provided an excellent chance for the lead to take a step back, carrying out a clear and thorough ABCDE

Areas for improvement
Lead could have delegated more tasks to colleagues around them, freeing up capacity and helping them to see the bigger picture. This ties in with our comms point regarding positioning at bedside.

Analysis (with aviation crossovers)
There were some excellent task assignments, including delegating a review to the assisting doctor and using another doctor to take care of the distressed parent. That said, we still felt that there were more tasks that could have been carried out by other team members (IO Drill). It’s clear that the lead had a high level of ability, however, sometimes giving these tasks to a colleague generates a great deal of empowerment. 

The parallel would be operating into an airfield with a particularly complicated approach. Sometimes it is favourable for the captain to fly, however, it is important to remember that the first officer will become a captain themselves one day. By delegating the approach (whilst still carefully monitoring performance), a captain provides the first officer with an opportunity for skill development. Additionally, we find that delegating tasks leaves us with extra capacity to cater for any sudden changes or distractions later down the line.

Situational Awareness

Positives
After the frenetic start, good general time awareness by the lead. At no point was there any rushing from team members.

General awareness of the patient‘s state at all times was high thanks to several ABCDE reviews including the delegation of one to the assisting doctor. This is an empowering move and raises SA for all colleagues.

Good projection of knowledge, verbalising the main threats at all times and thinking aloud during diagnosis.

Areas for improvement
It would have been nice to see more open questions – “have we missed anything?”

There were team members on the periphery who were almost 5m away from the patient and, because of this, obtaining items from the crash cart seemed to be quite a drawn out process. Try to bring the more distant members into the equation. One way may be to ask them how serious they think the situation is?

Analysis (with aviation crossovers)
Some excellent reviews, including a thorough ABCDE by the assisting doctor, raised the situational awareness significantly within the team. In aviation, the use of PPP (plane, path, people) gives pilots the opportunity to assess the status of the aircraft, where it is heading, and who they need to speak to.

During the simulation, there was a clear gap between the team next to the crash cart and the team around the patient. While there is a required cart spacing due to Covid procedures, consider how you can mitigate the issue of distance between team members. Despite a cockpit door remaining locked throughout flight, there are regular calls made between crew and pilots to ensure SA remains high for the entire crew. 

Actively encourage your colleagues to express how seriously they perceive the situation to be on a scale of 1-10. If their answer differs significantly from yours, there may be a breakdown in situational awareness, which can be easily restored by asking them how they came up with their score – it could be you who is missing something!

Decision-Making/Problem-Solving

Positives
Excellent open question – “what can we do to improve oxygenation?” – from the team lead brought the room together.

Both the lead and assisting doctor asked lots of probing questions to help with the diagnosis.

Areas for improvement
Pressure test your diagnosis more. “Tell me why this may not be sepsis?”. Ask your experienced team members open questions.

Some ambiguity existed between the lead and anaesthetist as to whose decision it was to put in a central line –  “you are the lead, it’s your decision”.

Analysis (with aviation crossovers)
When problem solving an inflight failure, it is imperative to use all available resources to come to a decision (systems pages, fuel burn, engine parameters, smell, noise, cabin crew observations). We felt that the lead did a great job in asking the parent questions, looking at the vitals, and using thorough reviews to come to the diagnosis.  

Once a sepsis diagnosis was made, we would have liked to have seen more pressure testing of this decision – “tell me why we shouldn’t shut down engine number 1?”. This is a great way of including your team in critical decision making and it’s possible that someone may have a new point to make that goes against the consensus.

Take Home Points

1. Bring your team together at the start using the ‘Golden 5’ minutes if available.
2. Implement readback/closed loop communication to reduce errors.
3. Pressure test your diagnosis.

Many thanks,
Captain Alex Jolly and Captain Dave Fielding

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