Rapid Sequence Induction and Intubation. Incidence Reflection - Essay Example

?RSII Incidence Reflection Introduction This paper is going to focus on Rapid Sequence Induction and Intubation (RSII) a situation I came across during my placement. I will give a reflection of this incident as was performed on an obese patient during my clinical placement. This reflection is revolves around the interplay between interpersonal skills and poor communication during tasks performed by teams. Specifically, this reflection will focus on my actions, attitudes of the anaesthetist and role played by my mentor- an anaesthetic practitioner- in the process of handling this situation. In this reflection I have ensured that I maintain confidentiality in line with the Health Professional Council code of Conduct that demands the observance of the same, under code number two that states “You must respect the confidentiality of service users.” It informs me that I must treat information about service users as confidential and that I must not release any personal or confidential information to anyone not entitled to it (HPC, 2008, pp. 8-9). Therefore all names of the people involved in the process are treated as anonymous and I will different letters to refer to each one of them. I decided to choose this area for my reflection basing on a few reasons. First is that as a student ODP doing my clinical placement, it was my first time to come across such a major incident and therefore it made me curious. Secondly is that, I realized that this procedure is applied to all EG operations, making it commonly used. As a student on placement I realize the need to familiarize myself with the incident and procedures of operation as it is a common phenomenon in our daily lives. The last point is that, I engaged myself in massive research on this topic thereby developing skills and knowledge in this particular area. Rapid Sequence Induction Intubation (RSII) Rapid Sequence Induction and Intubation (RSII) is a medical procedure involving the fast induction of general anaesthesia and following intubation of the trachea. It is generally used in an emergency (EG) situation or for patients who have an increased risk of aspirating gastric contents into lungs (EL-Orbany & Connolly, 2010). The main objective of this technique is to minimise the interval time between loss of protective airway reflexes and tracheal intubation with a cuffed endotracheal tube (ETT). If the intubation is not attained within a maximum 2 minutes, the patient could suffer extreme morbidity or even death from hypoxia (lack of oxygen in body tissue). Therefore airway management is the most important skill for an emergency practitioner. Failure to secure an adequate airway can cause disability (EL-Orbany & Connolly, 2010). The decision to intubate the patient is sometimes very difficult to reach. The difficulty emanates because the situation requires high clinical experience so as to recognise the signs of an imminent respiratory failure. The concept of RSI was gradually evolved after introduction of Suxamethonium chloride/succinylcholine (paralytic drug) in 1951, and the description of cricoid pressure (CP) in 1961 (EL-Orbany & Connolly, 2010). The procedure include; oxygen administration, rapid injection of a predetermined dose of thiopental/barbiturate (group of drugs), immediately followed by succinylcholine, application of CP and tracheal intubation. It seemed from these components that the term; RSI which is used in both anaesthesia literature and emergency medicine are both inadequate. Because, the technique includes both anaesthesia induction and tracheal intubation, therefore the term RSII is more accurate and descriptive of the technique (EL-Orbany & Connolly, 2010, pp. 18-25) Reflective models My essay will employ the Rolfe et al. (2001) model of reflection to reflect on what I learnt and the experiences I went through. Reflective practice is an approach to learning and practice development that is patient centred and which acknowledges the untidiness and confusion of the practice environment (Price, 2004, p. 46). Practice environments are involve the management of risks, clarification of what is safe and acceptable to others and what will promote the collective image of the team- be it in the ward or any other place. Given this situations reflection and critical thinking is of essence and only becomes transferable skills if the mentor can help the learner to use them flexibly and share the discovery process with the rest of the team (Price, 2004, p. 47). Reflective practice is collegial and team focused, involves audit and quality assurance, involves problem solving, and is pragmatic and safety oriented (Taylor, 2003, p. 246-247). The idea behind the choosing of the Rolfe et al. model is that it is fairly simple and therefore would be very suitable for a novice like me. The reflective model poses three simple questions “what? So what? And now what?” The “what” is used to describe the situation that is, achievements, consequences, responses, feelings and problems (Orpet & Welsh, 2011). The “so what” is used to explain what has been learnt, that is, learning about self, relationships, models, attitudes, cultures, actions, thoughts, understanding and improvement. The “Now what” question is used to identify what ought to be done so as to improve future outcomes and develop learning. The proponents of this model believe that the last stage is of great importance in contributing to practice (Orpet & Welsh, 2011). A second most widely used framework of reflection is the Gibbs’ (1998) reflective cycle. This cycle consists of a series of questions that are used to guide the reflective practioner in decision making. It is divided into five stages. The first stage is the description and this explains the event, situation thoroughly, describing who was involved, the practioners role and results. The second stage involves desribing thoughts and feelings of oneself and others. The third stage involves evaluation and analysis and this describes what was good or bad about the situation, expectations and reference to prior knowledge. The fourth stage is the conclusion that identifies alternatives and information that may assist in making judgements an the last stage is the action plan that expalins what ought to be done differently next time and the learning as a result of the situation. The idea of reflection is important for healthcare professionals because first it empowers them and gives them the opportunity to unravel a complex situation, see it for what it is (Price, 2004, pp. 46), identify ways to ensure that a problem does not recur and or identify strategies that will improve outcomes in the future. Secondly for new graduates or trainees, the practice environment may not turn out to be what it first seemed to be as the trainees will struggle to hold onto the ideals of why they wanted to be nurses in the first place(Chang & Daly, 2007, pp. 277-279). Reflection therefore offers stability in such situations, something which a novice can turn to help make sense of the world and re-evaluate their practice (Bulman & Schutz, 2004, pp. 26-28). Reflective practice is essential for personal and professional growth as it helps nurses to habitually self correct and assist others in doing the same so that the whole notion of continuous improvements becomes part of who we are as nurses (Chang & Daly, 2007, pp. 277-279). The purpose of reflection can be seen to be in three fold. The first reason is to understand yourself in terms of motives, perceptions, attitudes, values and feelings that are associated with conduct of care. This helps practitioners to understand themselves and in this way they become more open to understanding the different perceptions that are held by others (Price, 2004, p. 47). Secondly reflection is done in order to view the practice from a new perspective and challenge the assumptions that nurses bring to practice episodes. Reflection is built on the fact that we all construct varied meanings and explanations about events and some of these might be misguided (Rolfe et al., 2001, 5-10). The third purpose is in order to discuss with other practitioners on how a situation could be approached differently (Bulman & Schutz, 2004, pp. 26-28). The learners in this sense are taught to think critically on possible consequences of their actions (Rolfe et al., 2001, 5-10). Analysis of the Incident I started my shift at seven thirty in the morning on Wednesday as usual. I reported to my mentor and started to prepare the intubation trolley as routine. Then, we both checked the anaesthetic machine and went through the operating list to check the number of the cases and the type of operations. This procedure is done every morning before World Health Organization (WHO) check because some of the intubation equipment can only be determined by the age of the patient and the nature of the operation (WHO, 2008, pp. 3-5). As we went through the operating list a realized that my mentor was writing some remarks on the third row, just beneath the last column that read allergy. I could read the remarks and eventually asked her. Her answer was simple, “I will explain to you when we get to the case.” Unable to insist I would say “Okay”. I wondered why she could not explain it before the operation and therefore my assumption was that may be the patient is allergic to some medication because of where the comment was made. I would then continue making the remaining preparations. In the end the theatre team did come together and the operations began. It was about 11 o’clock when we reached the third case of the patient with the remarks. My mentor had a few words with the anaesthetist standing next to the anaesthetic machine which I could not get despite the fact that I was very close to them. Afterwards she replaced the Laryngeal Mask Airway (LMA) which I had prepared and marked “Mr F” with the Cuffed Oral Endotracheal Tube (COETT) and then asked me to follow her. On our way to collect the patient she gave me a short quick explanation of the past medical history of Mr F. He said that the patient had a high risk of aspirating stomach contents into lungs and required a RSI and that she would do it herself as it required experience and ability to apply a CP. I was told to watch. I did not understand any of the two terms CP or RSII but nodded expressing understanding. We positioned the patient on the operating table in supine position, after confirmation form the surgeon and the anaesthetist that we got the right patient following the WHO checklist guidelines (WHO, 2008, p. 5). Then my mentor told me to swicth on the monitoring while she helped the anesthetist cannulate the patient. I began with the Oxygen saturation probe as I was informed earlier on that it should be the first to apply and remove during monitoring and this was followed by the electrocardiograph (ECG) dots and blood pressure cuff. After finishing with the monitoring, I noticed the anaesthetist struggling to cannulate the patient as she was swaping from left to right hand trying to find the radial artery. At that moment the patient began to show signs of anxiety characterised by abnormal blinking and changing of sigh direction and following the movement of the anesthetist (Tierney, Mcphee, & Papadakis, 2004, pp. 102-106). My mentor had taken a step forward to create a communication bridge with the patient so as to reduce the existing tension. I watched standing next to the intubation trolley and reflecting on the medical history of the patient told earler to me( Risk of aspirating stomach contents into lungs). While thinking about the situation, surprisingly the anaesthetist panicked as well. She made it obvious asking for help from my mentor to help squeez Mr. F’s hand. The panic I thought resulted from the difficulty in finding radial artery which delayed the cannulation and the entire operation. I laughed silently about the panic and thought it to be baseless as she, as a trained practioner should be composed (Wendy Austin, 2010, p. 300). Ten minutes afetr applying the monitorng had elapsed and yet the patient had not been cannulated. My mentor asked me to call another anaesthetist to help but it took me time to find one and by that time they had managed to cannulate the patient.calm returned as the patient was pre-oxygenated for three minutes. This is done so as to wash the nitrogen out of the lungs, to create an oxygen reservior andf to provide vital safety gap during induction process. This is called Desaturation Safety Period (DSP)which is followed by pretreatment and induction (Langeron, Amour, Vivien, & Aubrun, 2006, pp. 243). I had already forgotten what the anaesthetist had told me and so I moved forward and handed the laryngoscope to the anaesthetist. Unfortunately I released it before she could grab it making it to hit the patient before dropping on the floor. My mentor rushed and picked it up, changed the blade and handed it over to the anaesthetist who was calm without a word. My mentor told me to watch as she performed the operation. I felt incompetent and unable to perform simple tasks. I lost concentration as I felt ashamed of the incident. Looking over I saw the surgeon and the scrub nurse waiting for us as tears stung my eyes making me forget my environment. I criticized myself as my mentor told to take a break and add that is should take my time because the case would take long. During the break I reflected on the incident asking myself why I did that as I had been told not to intervene at the intubation stage. The solution I found is that I was eager to learn. When I got back after the break, my mentor took me through the whole process of what happened giving me advice on handling, listening and following guidelines. I swore never to forget that incident. I learnt a lot from the incident: incompetency, poor interpersonal skills, breach of guidelines and selfishness. I should not have released the laryngoscope before the anaesthetist got hold of it. The consequences of dropping laryngoscope on the patient could be serious if he was not covered with a warmer which acted as a barrier. It could have broken or hit our toes. Although the patient was composed, she was not happy. The only salvation was my mentor as she had great skills. It is selfish to laugh at team members while struggling to save a life. I felt bad about this; I would have rather asked if they needed any help. It was bad to go for break in the process missing the rest of clinical experience which I was looking forward to. I would have waited to ensure Mr F was not affected by the hit. When my mentor also did not reply to my question initially I found out that she did not want to confuse me on something I had not come across. I should have been persistent instead of assuming the patient was allergic. I made poor judgments and also failed to ask about the RSI, nodding my head that I had understood instructions. I believe this was the cause of the accident because had I known the severity of the case I would have stayed away. I also aggravated the matter by losing concentration. Although I take responsibility for what happened, my mentor could have intervened by stopping me or reminding me of what she had earlier said. This would have averted the accident. Despite that she did a good job handling the situation. The anaesthetist is also to blame for remaining quiet as this was her patient too. I do not think it was professional and she needs to check her attitude and interpersonal skills. Reflective practice considers both positive and negative aspects of an incident. The positive aspects in this incident was my ability to detect Mr F’s anxiety and discomfort, the protection he had on that prevented him from harm, and most impressive, my talented mentor. The negative aspects include my incompetence, failure of my mentor to act after foreseeing danger and the anaesthetist bad attitude. However when I look at the situation form another angle I find many unanswered questions: what would have happened in case the patient died or died? Who would be responsible? Will the anaesthetist have remained quiet? Do I need to tell Mr F about what happened when he woke up? Or it would be comfortable to remain quiet to avoid awkward discussion. I believe the anaesthetist should be punished for delaying the operation, display of negative attitude and keeping quiet when the patient was hit. Conclusion Reflective practice is about personal and professional development (Price, 2004, p. 46). Developing this skill means developing ways of reviewing your own learning style so that it becomes routine that developes continuously during your career (Bulman & Schutz, 2004, pp. 105-108). This incident revealed to me the need to improve my interpersonal skills. People with good interpersonal skills are usually successful in their professional and personal lives (Stein-Parbury, 2009, pp. 4-5). There are several ways for on to improve their interpersonal skills and these include the following: putting on a happy face, showing concern and care, being considerate of other people’s lives, being a good listener, promoting team work and avoiding disputes. I am sure these will help me in my career and in the way I speak and listen to patients (Hayes, 2002, p. 95). I will also continue asking questions in areas that I am not sure about and never assume anything. I will continue doing my research in communication skills until I feel competent enough. I have also learnt to follow guidelines,regulations and ethics as laid down in the nursing and midwifery council guidelines of conduct (NMC, 2011, p. 4). I am also planning on following my mentor’s advice, doing research on cricoid pressure and RSII. I can now work safely fully aware of Manual Handling Operations Regulations (MHOR 1992) as well as Provision and Use of Work Equipment Regulations (PUWER 1998). I am clear on my limitations and would not approach a task until I am fully trained. I plan to strengthen my weaknesses and concentrating on my clinical practice. The Rolf et al. (2001)reflcetive model has helped me structure my thoughts and feelings and enhanced my level of awareness. The model is of great importance and can help practioners in many ways and thus contribute to safe working environments. Word count 3054 List of References Bulman, C., & Schutz, S. (Eds.). (2004). Reflective Practice in Nursing (3rd ed.). Oxford: Blackwell Publishing. Chang, E., & Daly, J. (2007). Transitions in Nursing: Preparing for Professional Practice. Sidney: Elservier Australia. EL-Orbany, M., & Connolly, L. (2010). RApid Sequence induction and intubation: Current controversy. Anesth Analq, 110(5): 1318-25. Hayes, J. (2002). Interpersonal skills at work. New York: Routledge. HPC. (2008, July). HPC standards of conduct, performance and Ethics. Retrieved January 2, 2012, from Health Professionals Council: http://www.hpc-uk.org/assets/documents/10002367FINALcopyofSCPEJuly2008. Langeron, O., Amour, J., Vivien, B., & Aubrun, F. (2006). Clinical review: Management of difficult airways. Critical Care, 10(6): 243-246. NMC. (2011, November 01). The code: Standards of conduct, performance and ethics for nurses and midwives. Retrieved February 3, 2012, from Nursing and Midfiwery Council: http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/ Orpet, H., & Welsh, P. (2011). handbook of Veterinary Nursing. New York: Wiley- Blackwell. Price, A. (2004). Encouraging reflection and critical thinking in practice. Nursing Standard, 18 (48): 46-52. Rolfe, G. (2001). Critical reflection for Nursing and the Helper Professions: A users' Guide. Basingstoke: Palgrave. Stein-Parbury, J. (2009). Patient and Person: interpersonal skills in Nursing. New York: Elservier health Sciences. Taylor, C. (2003). Narrating practice: reflective accounts and the textual construction of reality. Journal of Advanced Nursing, 42 (3): 244-251. Tierney, L. M., Mcphee, S. J., & Papadakis, M. A. (2004). Current Medical Diagnosis and Treatment. New York: McGraw-Hill. Wendy Austin, M. A. (2010). Psychiatric and mental health nursing for canadian practice. New York: Walters Kluwer Health. WHO. (2008). Implementation Manual Surgical safety Safety Checklist. Geneva: WHO. Read More