SCCM Resource Library-Critical Care Nursing at 35,000 Feet: How Different Can It Be?

Video Transcription

Welcome to the 51st Critical Care Congress. Hi, my name is Captain Ronnie Ramon. I'm a critical care nurse at Brooke Army Medical Center for St. Houston, Texas.  At this time, I will brief you guys who got critical care nursing at 35,000 feet. How different can it be?  Disclaimer. All information included in this presentation is unclassified.  The views expressed in this presentation are my own and should not be contrived to represent the position of the Defense Self-Agency,  the United States Air Force, or Department of Defense. I have no relevant financial relation to disclose.  Individual products are discussed for historical or informational purposes and may not reflect current standards of care. Let's ask ourselves hypothetical questions.  For example, we're transferring a TBI patient and the patient has hypotension. What is the threshold to intervene?  Are we familiar with the equipment and where it's bowel signs display shown in our monitor?  How about if another complication occurs, for instance, hypoxemia and the patient presented with elevated ICP? What is the design symptom they will present? The second example.  We're transferring a patient with the right chest wall trauma and intubated. And of course, we won't be able to see the shortness of breath at that time.  And if a pneumothorax occurs, how will you recognize it? Did you have access to do the intervention? The third example.  If we're transferring a STEMI patient, what is the possibility complication during the flight? Does each team member aware of the same symptom of complication?  Learn from the previous slide. There are many possibility complications can occur during a transport. Before our mind wanders, let's wheel back in to the base.  Let's talk about crisis resource management. What is effective crisis resource management?  So crisis management is referred to the non-technical skill required for effective teamwork in the crisis situation.  Another part is like knowing your environment, preparing and anticipating, then providing effective care to your patient.  And of course, crisis resource management training improve performance and reduce error.  There are a few factors that can affect the team performance. One of the factors is the complexity of the task. It's like how much time do I have before the wheels up?  And then who is or where the patient located? And what type of information I will receive before the mission is how many patients I will get or what type of injury they have.  And what type of intervention they already receive. And the next factor is like how is my well-being? Do I will be able to have something to eat before the mission?  How is my personal life? Because oftentimes the personal life will affect how you. Performance during the mission. And how is the team cohesion?  Is each team member aware their role? And how each team member will communicate during the mission? And the environment factor is where are we going to have the handover?  And what interruption we will get? Do we will under fire?  Do we will do it in the flight line if the airplane will be able to turn off their engine so we can have a clear communication between the ground team and the critical care transport team?  And is our equipment will work properly during the transition? As you guys are aware from the previous slides, there are as many things that can affecting the team performance.  And the next few slides, I would like to discuss a few things that can negating the factor affecting the team performance.  In here, I will highlight the situational awareness. How the team communication. Prioritizing and teamwork and routine.  The first key on the crisis resource management is situational awareness, and I divide those to a two subcategory medical and team situational awareness.  The medical situational awareness is like where I know what's going on with each individual of my patient that I'm taking care of.  Because if I know what's going on in each one of my patient, just in case if any emergency arise, I know how to intervene or I know how to do intervention on them.  At the same time, we have to know what the status of the non-critical patient as well.  Even though we are not the primary caregiver for those patients, but during the mission, we are at or have a role as the rapid response team.  If those patients end up deteriorating or have some type of emergency, we are able to respond because we know some type of general idea on their medical background.  On the team situational awareness side is where each team member aware of the tasking need to be completed.  For instance, because I have three different patients and in one of the IV fluids almost right now, I will not aware of that and my RT able to aware and they can replace those fluids so we'll be no stoppage on the care.  At the same time, the each team member have a clear communication with each other so we are aware of what's going on at all the time.  They will bring up to the next point, which is communication.  The communication type that we use during this type of mission is closed loop communication.  Because it's where I describe or communicate on something and the other person acknowledge it with respond back.  Because we learn or we train where if you don't hear and respond, it's my assumption is they did not hear you. With that, it's easier to eliminate miscommunication or assumption.  At the same time, we use the same share metal model.  Where we have the same understanding what's going on and which plan we're going to use so we all have the same mentality what our expectation of each other.  After that, we have to remember how much communication that we're going to use.  Because if we talk all the time, it will crowd the airway and it will make us to ignore, to be fatigued with all the noises.  And then they will cause the impact of the communication itself.  To have effective prioritization, we have to start with a good situational awareness and the great communication within the team.  Each team member has to understand what the big picture is to have effectively prioritize our tasks. We have to understand what matters right now.  Oftentimes, on this type of mission, it's very test saturating. And we have to know where we have to order our task and which one is more important at present time.  We have to know who is available in team to complete the task or moving to the next task. Because that's why great communication plays a role.  Because we will know each other's strengths and what are each other's weaknesses. If you're really strong on the setting up the pump and I'm really strong on setting up the SME.  So I can start doing set up the SME and you set up the pump or the other way around.  That's where in the end, so we all know and you know the big picture is to set up the patient, stabilize it and start transform process.  Teamwork. To have successful mission, we have to have a great team dynamic.  And to have a great team dynamic is start with who's leading the team. The team lead had to have open communication and able to taking suggestions from the other team member.  And always have the critical mindset that relying on the why whenever possible instead taking the reason of because this is what we do in the past.  At the same time, team lead had to be able to assuring that everyone is engaged on the completion of the mission.  On the teamwork, everyone had to be aware the critical role and what's the critical limit on everyone have.  I always try to volunteer ideas how to make process better instead complaining about how the work suck.  And when you notice that when you start test saturating and you start get behind, just try to asking for help early so we can have start process to helping you or we had to make ensure the testing is completed in appropriate time.  And to alleviate all this extra stress is to know your resources, learn the inside out of your allowance standard, a plan ahead when we have a time on the time frame when the wheels goes up, the type of patient we're having or what type of injury they have.  We can plan ahead of preparing extra supply, extra medicine because once we up in the air is no more or there's no central supply, they can send a supply just in case if we need them.  And after that, know each team member strength and limitation.  We cannot provide the task to somebody if they feel uncomfortable with it.  So that's why if you know your team strength and limitation is making the team dynamic perfect and the success of the mission will be higher.  At the same time, we always fly with the AE crew, the air vac team.  And sometimes just by knowing them, what is their capability because oftentimes they might doing just standard nursing care in the air, but on the outside, they're doing like critical care or the emergency nurses or CRNA, anesthesia.  So with that said, you can respectfully understand what their capability and their knowledge level.  So just in case the emergency situation arrive, that you can ask them and you have full confidence they will be doing the work appropriately and get the mission successfully.  And when anything come to job, you always can try to phone a friend.  What I meant is sometimes we have the ability to communicate with the ground team or the incoming facility to ask for resources.  For instance, if we have to do ECMO transport from different state, we have the ability to contact with the internet connection that we have on the plane to contact the ECMO team back in Bamsi.  At the same time, if we have a burn patient, we stuck on certain type of procedure or intervention, we can contact the burn unit at Bamsi to how to care for this patient.  And after time, chaos happen and it is our job to regain our control. Do what is work for you. For me, it's control what you can control.  First, stay calm. Because if you start getting out of control, you just dig yourself a hole and you start thinking and you start snowball reaction.  Do what is work for you. Time out, silent or pause, breathing exercise. I pull out reference card because oftentimes when everything go chaos, I forget what it is.  So when I pull out the reference card, I start going back and bring myself to earth. I say, hey, this patient have hypotensive due to bleeding. What should I do?  And I start getting pull those reference card quick. Pre-planning. And this oftentimes is the pitfall. Start thinking what possible could happen before they occur.  This is nice and dandy if we have plenty of time. But when time is absent, sometimes pre-planning can be difficult. So oftentimes when we have a little time, we just start working the problem out in our head.  And open communication with your team. And then just don't always think have the negative thinking. This is impossible. But always try to be in the positive side. Always try to give yourself pat on the back just because most often this is difficult tasking.  Not everybody can do it. So that's why you have to give yourself a prop to give yourself a boost that you are important to this mission.  Throughout all this deployment that I learned myself, what if work for me? What is my limitation? With this, we move toward yellow. Is this what's your focus is on the alert side, but does not make you to be overwhelmed.  To optimizing program and during the transport is no location of the supply and equipment, including function of the equipment. When it's downtime, make a time for regular training because when the chaos, you have to rely on your muscle memory.  Know the team member role and level of the experience. Not everyone built equally and not everyone have the same level experience.  Always re-evaluate and re-prioritize test regularly because it's not only going to keep the situational awareness, but also reduce the saturation. And when the tasking is getting saturated, ask for help early.  In summary, plan ahead because when you in the air, you are it. You do not have anybody else that can bring you more supply. When the supply is gone, it's gone.  Continue situational awareness through good communication. With that said, continue talking with each other so you know the big picture how the mission will be success.  Always re-prioritizing frequently depends on the situational. Recognize the adrenaline can make us sharp to a point, but ultimately, if we have too much of it will make us prone to error.  Please let me know if you have any questions and thank you.

Video Summary

Captain Ronnie Ramon, a critical care nurse at Brooke Army Medical Center, discusses critical care nursing at 35,000 feet. He addresses hypothetical scenarios and complications that may arise during patient transport, emphasizing the importance of effective crisis resource management. Factors that can affect team performance include task complexity, environment, personal well-being, and team cohesion. Situational awareness, both medical and team-related, is crucial for effective communication and intervention. Closed loop communication and shared mental models help eliminate miscommunication. Prioritization is based on situational awareness and effective communication, considering the urgency and availability of resources. Teamwork involves open communication, understanding team dynamics, and utilizing each team member's strengths and limitations. Pre-planning and maintaining control during chaotic situations are essential, as is regular training and evaluation of goals and tasks. Overall, planning ahead, maintaining situational awareness, effective communication, and prioritization are vital for successful critical care nursing during patient transport.

Asset Subtitle

Crisis Management, 2022

Asset Caption

Military medical teams uniquely need to be able to manage the transport of critically ill patients, regardless of the nature of their illness, over great distances to receive definitive care. These teams must be able to deploy at a moment's notice and care for patients with complex polytrauma, acute respiratory failure, highly infectious diseases, and possibly children as well as adults. This session will review the capabilities and experiences of the U.S. military's critical care air transport (CCAT) teams, as well as lessons from their work that may be broadly applicable to "earthbound" critical care.

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Nursing

Tag Evacuation

Year 2022

Keywords

critical care nursing

patient transport

crisis resource management

situational awareness

teamwork

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