A. Elaine Bromley is a 37-year-old mother who underwent sinus surgery on March 29, 2005. After performing routine anesthesia, an anesthesia consultant tried to control her airway. She was unable to find her laryngeal airways (sizes 3 and 4) as well as her oxygenation began to deteriorate. During this period, her oxygen saturation was 75% and it continued at 40% for the next 4 minutes, when the anesthesiologist tried to ventilate with 100% oxygen. Thus, intubation was attempted at 6-9 minutes and other anesthesiologists consulted the adjacent theater in this case. Oxygen saturation is still 40% within 10 minutes and tracheal intubation is attempted, but laryngeal anatomical assessment proves difficult if insight is not possible. The anesthetist continued continue to attempt to imitate Mrs. Bromiley. After 35 minutes, it was decided to wake Mrs. Brumley. During this time, her saturation is less than or equal to 40% in 20 minutes. She had suffered brain damage and was never found consciousness. Hence, she died 13 days later.
As I have seen, situational awareness is a part of everyday events in complex and risky situations (such as drivers evaluating potential septic patients or pilots evaluating potential runways). In all cases, situational awareness includes a number of cognitive functions like understanding, perceiving, thinking, and reasoning that influence our actions and decisions. Situation awareness theory is often used to explain that decision makers can integrate knowledge from the environment in such a way that they understand “know what is going on around them” and make critical decisions”. Mehta et al. (2017) proposed that all elements of the environment that are related to the unknown make this understandable decision. The important thing is how to decide how these factors affect and influence the situation over the period. Schulz et al. (2017) proposed that situational awareness can be divided into three levels, like projection, comprehension, and perception. The integration of these three levels is best described as “understanding the elements of the environment with a specific time and place, its meaning and its location in the near future”. This is important to mention the difference between situational awareness as a level of knowledge and situational awareness as a process.
To illustrate the critique of situational awareness in a clinical context, many medical training programs use the following practical truth:
Bromiley was a healthy and fit young woman who has been hospitalized for routine sinus surgery. While performing anesthesia, she experienced problem of breathing and the anesthetist could not attach any device to secure her airway. After 10 minutes, this was a condition of “can’t intubate, can’t ventilate”; emergency anesthesia is recognized for existing guidelines. Within 15 minutes, three experienced consultants tried to reach Elaine’s airways as well as she experienced prolonged periods with extremely dangerous low oxygen level in her bloodstream. Initially the nurse informed her team that she had brought emergency equipment to room as well as booked the bed in the intensive care, however, it had not been used. After 35 minutes the onset of anesthesia, Mrs. Bromiley was allowed to wake up normally and was transferred to the recovery unit. When she failed to wake up, she was then transferred to the intensive care unit. Also, she never regained consciousness and 13 days later, she decided to withdraw ventilation support to save her life (Mehta et al. 2017).
Nurses work in complex environments that require constant attention to a variety of signals to maintain patient safety through supervision. The situation does not follow the guidelines of the recognized Difficult Airway Society, the management “cannot create internal conditions, cannot ventilate”. In particular, it takes longer to try to internalize the trachea than to focus on ensuring adequate oxygen in other ways, such as direct access to the trachea. Physicians become careless over time as the theater staff make sure all the necessary equipment is available and they miss the opportunity to limit the amount of damage caused by hypoxia over a long period of time (Wiggins et al. 2020).
As mentioned above, in the alternative situation the ventilation problem that has already been solved, there is no indication that the patient is unconscious and he should be allowed to breathe and wake up spontaneously. This will allow you to consider the problem and create alternative strategies in the future. However, in situations like Mrs. Bromiley, if prolonged gross hypoxia (up to 20 minutes) is almost unavoidable, there can be at least some annoying or actual damage. Such damage can be reduced by maintaining adequate oxygen and ventilation. The development of inadequate ventilation leads to a decrease in oxygen and an increase in levels of carbon dioxide, both of which are harmful to the brain in damaged conditions. After this long hypoxic period, it is better to provide time for controlled ventilation and observation of the brain than to leave the patient trying to wake up and ventilation may be reduced. Doing this line requires a bronchial insight that is already known to be difficult if not impossible. In my opinion, operating airway access should be considered another because it not only provides a safer airway, but also allows optimal postoperative ventilator treatment (French et al. 2018).
For long-standing hypoxia, I believe Mrs. Bromiley should have been admitted to the intensive care unit. He had to order a safe flight and his lungs had to be ventilated. Moreover, such aggression should be monitored to best control blood pressure. All the skills and equipment to do this are available in clinical operating theaters. They come back conscious and breathe spontaneously and it doesn't help to damage the existing brain no matter what. Ensure that the communication environment in the operating theater is good so that the stranded staff is giving advice on treatment. In the case of anesthesia or operating theaters, the protocol works to maintain records of contemporary events and to nominate people to give early deadlines. It is clear that physicians still do not know the specific features of some of the tools used. This can be fixed within the day of the study to manage the airways for all staff, including physicians.
The process of transferring care from anesthesiologist to rehabilitation staff should be made more formal so that there is no confusion as to who is responsible for caring for the patient. Under no circumstances will the physician be committed to taking care of another patient until the patient's previous treatment has been transferred and the jurisdiction is recognized. After a major incident here, the staff involved, including the doctors, did not resume work immediately. All staff need time to reflect and ensure that all documentation has been completed. Ideally, the list of other group operations should continue, but there should be at least one break. Action suggested: The main event of employee participation should be forced to stop work before the top of the list (French et al. 2018).
When working between gynecology and obstetrics, we often work in risky environments usually delivery suites or cinema halls. The transition between high-and low-risk treatments can have immediate and adverse consequences that can occur without caution. So, it is important that because health professionals work in this environment, we can understand and develop cognitive skills, including awareness of the conditions necessary for the safe care of patients. The development of these non-technical skills includes communication, decision-making, situational awareness, leadership, and teamwork to enhance overall security (Marshall and Chrimes, 2016). There are several changes are required about nursing situational awareness in the context of clinical practice to enhance the assessment and management of worsening patients:
Communication between team members is important. In the case of Elaine Bromley, the process of communication fully dried up. There are three senior and experienced physicians in the room- physicians - one ENT consultant and two anesthetic consultants. But they don’t communicate with each other and no one is talking about what’s really going on (which means this patient has a problem, it is a “can’t intubate, can’t ventilate” condition). The key to recreating the situation is to maintain clear communication. Other team members must understand what is going on as well as it can support the team make a suitable plan (Schnittker et al. 2018).
The team planned to begin with a laryngeal mask but when it failed it was the only option considered as tracheal intubation. Also, they tried to use masks of different sizes for bagging, but without them SAT continued his insertion effort for 25 minutes or even 40%. There must be a clear plan before starting any process. There is no need for more than an intuition plan. Algorithm of any local airline - look better. Also, vocalizing is important. Talking to the team prior to the process begins, every person knows what will go on after the crisis (Marshall and Chrimes, 2016)
In the case of Elaine, there were three physicians and three experienced nurses. While the clinicians did not recognize the seriousness of the circumstances, the nurses knew it. In the resus, the nurse brought the surgical airway kit and informed the consultants that she had brought it - but there was no response. Then again, one of the other nurses wanted an ICU bed at the start of the break - when she told consultant it, they made her feel like she was overreacting (and she canceled this). The nurse did not know how transferring staff could improve the problem with the physician. Each member of the team should be able to show boldness, especially when it comes to understanding the problem and getting advice for solutions. But there has to be a culture of listening more than that. Each team member may have some effective and useful additions. Asking about occurrences and offering potential alternatives is a vital part of resus as well as it is important for good teamwork. All people have voices and everyone has to listen (Coyle et al. 2020).
In this case, the main anesthesia “lost control” and lacks clear leadership. Some people have to take responsibility for the situation again. The job is to show what is actually happening, to monitor all situations and plans for alternatives. Without the good leadership, there are many people who strive to accomplish their objectives.
In a word, perception is a key element of situational awareness. During our daily practice, we are exposed to a wide range of information and communication, such as electronic, written, non-verbal, and verbal. Awareness of the situation can be raised by making clear decision-making, keeping quality records and using structured submission tools for communication - improving the quality of information provided by decision-makers. Effective handover must be multidisciplinary, confirming that introduction is carried out daily because team is not fixed as a regulation. Using structural handover tools like delivery suite board, we create a psychological model together as a team. The board should be accurate, legible, concise, and up-to-date. The board’s information supports our perceptions that help us build our perceptions after discussions with multidisciplinary team - taking information from communication and putting it in an environmental context (Coyle et al. 2020). Thus, as a healthcare staff, we can record estimates (plans) to the board to make all team members aware. After gathering information about situational awareness, it is important to communicate with all team members. It is the core of share mental model.
Coyle, M., Martin, D. and McCutcheon, K., 2020. Interprofessional simulation training in difficult airway management: a narrative review. British Journal of Nursing, 29(1), pp.36-43.
French, J.P., Maclean, D., Fraser, J., Benjamin, S. and Atkinson, P., 2018. P050: How aware is safe enough? Situational awareness is higher in safer teams doing simulated emergency airway cases. Canadian Journal of Emergency Medicine, 20(S1), pp.S74-S74.
Gardner, S., Nesi, H. and Biber, D., 2019. Discipline, level, genre: Integrating situational perspectives in a new MD analysis of university student writing. Applied Linguistics, 40(4), pp.646-674.
Marshall, S.D. and Chrimes, N., 2016. Time for a breath of fresh air: Rethinking training in airway management. Anaesthesia, 71(11), p.1259.
Mehta, A., Martin, M.J. and Horelik, N.E., Rapidsos Inc, 2017. Method and system for situational awareness for emergency response. U.S. Patent 9,659,484.
Mehta, A., Martin, M.J. and Horelik, N.E., Rapidsos Inc, 2017. Method and system for situational awareness for emergency response. U.S. Patent 9,756,169.
Schnittker, R., Marshall, S., Horberry, T. and Young, K.L., 2018. Human factors enablers and barriers for successful airway management–an in‐depth interview study. Anaesthesia, 73(8), pp.980-989.
Schulz, C.M., Burden, A., Posner, K.L., Mincer, S.L., Steadman, R., Wagner, K.J. and Domino, K.B., 2017. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain DamageA Closed Claims Analysis. Anesthesiology: The Journal of the American Society of Anesthesiologists, 127(2), pp.326-337.
Wiggins, J., Woodward, L. and Vaughton, A., 2020. The'Airway Assistant'-a visual guide to difficult airways. Trends in Anaesthesia and Critical Care, 30, p.e98.
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