Situational Questions Flashcards
You have a colleague who your anaesthetic assistant says is always tired and yawning and it is affecting his work. What do you do?
S
- impaired colleague welfare SIG document
- establish facts, document them (critical incident reports, complaints by patients/colleagues)
- ask assistant for examples of effecting practice
P
- Impaired vigilance, clinical judgement and motor skills
- Leads to an increase in clinical incidents
- Individuals often unable to recognise their own fatigue
I
- discuss with the colleague if appropriate, take time to listen to them
- encourage them to seek help from appropriate supports if required
E
- discuss with trusted senior colleague
- Moral and ethical responsibility to report if unsafe (discuss first)
- consider discussion with indemnity agency
- Policies obligating appropriate rest times between shifts
S
- encourage colleague to seek support
- do not take duty of care
- senior staff to arrange clinical review or restrictions on practice if required
What do you do if you’re the anaesthetic registrar on-call and you get a call from ED about a patient needing urgent intubation and no-one else is available to do it?
S
- Clarify reason for intubation, patient situation, urgency of intubation.
- Who else is available (ED/ICU boss/SR), how far away on call consultant is
P
- Risks of intubation
- Risks of unprotected airway
I
- Assess patient - Need for intubation, ?difficult airway, previous intubations
- Basic airway manoeuvres, adjuncts, suction, alternatives e.g. NIV
E
- Call consultant or ICU for help early ?wait for consultant vs intubate now
- Attempt intubation if necessary
- Staff - 2x senior anaesthetic assistant, drugs doctor
- ICU (will be going there after)
- Monitoring
- Equipment - video laryngoscope, difficult airway trolley, bougie in first instance
- Plan - Vortex model, RSI
S - re-evaluate patient
- Re-discuss with supervisor, feedback
- Team debrief
- Self care
- Documentation
- ? Open disclosure
- ? MDA
- update patient family
What would you do if you’re asked to go and see a patient in ED with haematemesis and melena with view to anaesthetise for gastroscopy?
- assess over the phone - vitals, GCS, estimated loss, Hb, pressors/blood products given
- notify boss, gastro team to prep theatre, anaesthetic tech
- ABCDE assessment
- Pre-operative assessment: AMPLE
a. PMHx, PSHx, anaesthetic Hx. (from staff/pt/chart/family)
b. Allergies, medication, fasting status
c. Airway assessment
- Call consultant again with update and formulate plan
a. Airway - RIntubation with RSI
b. Ventilation
c. Circulation - large bore IV, blood and fluid ready
d. Keep warm
Boss not wanting to come in when required
S - Why cant they come in P - Keep patient in ED - Communicate situation to parents, their safety is paramount I - explain what in particular you are uncomfortable with - Graded assertiveness - PACE Probe - why can't you come in Ask - Don't you think this is a critical situation I need help with Challenge - If you don't come in I have to call the director Escalate - I am calling the director E - Call other senior or director - Inform surgeons so they are aware you are unsupported +/- patient and ED staff - Document concerns - Consider calling MDA S - Support patient - Self care/debrief
Consultant managing patient against guideline recommendations
S
- Clarify why the consultant has chosen a certain plan (patient may have declined initial plan, guideline may not be suitable to patient, may be aware of more recent evidence)
- Do this in an inquisitive way for your own learning
- Ensure they have all the information available
P
- Assess whether this plan will be safe for the patient
- Damage to doctor patient relationship if you raise concerns infront of patient
I
- Suggest alternative plan and clarify why they think this isn’t optimal
- Using graded assertiveness state that you do not think this plan is safe
E
- Get second opinion from another consultant if still not satisfied (you may still be wrong)
- Do not do this in the presence of the patient (damage doctor patient relationship)
- In an emergency situation, go with consultant’s plan and document your disagreement (including that you raised this fact) and reason for this so you are not legally accountable
? Reportable
? Departmental teaching session / M&M case
S - Learn from experience (if consultant was right)
- Further reading on topic
- Self care if poor outcome and feelings of responsibility
You’ve just done a night shift and your boss asks you to do a morning list because of short staffing. What is your response?
S
- Clarify they are aware you have just done a night shift and are fatigued
- Find out why they are short staffed and if they really need you
P
- Shouldn’t be working if you feel impaired
- great deal of evidence that fatigue impairs outcomes
I
- If feeling unsafe —> Graded assertiveness (PACE)
Probe - is there anyone else
Ask - why are you making me work fatigued
Challenge - I don’t think this if safe
Escalate - I’m informing the director
- If not entirely fatigued negotiate safe practice (not in direct patient contact, supervised/supported practice, opportunity for some rest prior to starting
E
- Escalate to director
- Report and document
- Consider discussing with MDA
S
- Self care
You’re an anaesthetic registrar doing multiple nights and you’re anaesthetising someone for an appendicectomy. Things are going fine until all the power goes out. It is dark, and no emergency back-up power comes on. There is only the surgical registrar, the scrub and scout nurse and the anaesthetic nurse in the room. What do you do?
S
- DRSABCD
P
I
- Cease operation
- Nurses to phone after hours manager + boss + NUM and get torch
- Ensure ABCD intact - tube, ventilation (may need to bag), IV access, ensure battery in pumps, switch to TIVA
- may be no monitoring so manual vitals
- discuss with surgeon safety of close vs finish operation
E
- Notify seniors and NUM
- Document + call MDA
S
- Support patient and staff
- Cause analysis and changes to prevent this again
How would you deal with conflict e.g. with a recover nurse?
OR
Difficult Colleague
S
- Seek information on what is causing the problem
- Try and understand the problem from their side
P
- Do whatever needs to be done to ensure the patient is safe
I
- Explain your side and negotiate
E
- Escalate to senior staff if unable to resolve conflict in a way that is safe for the patient
S
- Remain in contact with person after the situation is resolved, discuss what happened and why in order to prevent future conflict
Working in an ICU a patient comes back from theatre following a maxillofacial procedure, who starts having difficulty breathing and desaturating. How would you manage this situation?
S - Handover from nurses P I - DRSABCD Send for help - assign roles Airway manoeuvres/adjuncts/ETT B - 100% O2, BVM/venilator C - IV access Check op notes ? Throat pack ? Airway grade E - Call seniors early + Maxfacs +/- MET - Document S - Notify patient and family - Debrief with staff - Personal care Reflection - ensure ALS competency
Sick patient with unsafe airway. Consultant on call says he’s busy and doesn’t want to come in. What do you do?
S
- Patient condition
- Why are they not able to come in
P
- Call for help
- Basic airway management, adjuncts, suction, oxygen
I
- Graded assertiveness
E
- Escalate to director if not coming in
- Document and consider contacting medical indemnity
S
- Debrief with consultant and director on what happened
- Get feedback on handling of situation
- Self care - debrief with appropriate supports
Anxiety/Depressed colleague
S
- WOASIG statement
- Look for signs (reduced performance, mood, motivation, weight gain/loss, reduced self care, absenteeism/withdrawal)
- Share concern with others, including nursing staff
- consult supervisors/WOASIG rep/doctors health advisory service for advice
P
- Determine if this is a threat to patient safety
- Is the colleague safe
I
- Consider involving person’s partner/family
- Determine best person to approach the colleague
- Approach in an appropriate confidential setting
- Foster environment of care, openness and support
- May need to try multiple times if initial approach rejected
- Get the story from the perspective of the individual
- Encourage to seek help
- Advise them on available sources of support: welfare of anaesthetists SIG, doctors health advisory service, Mentor, Supervisors, GP, Employee assistance program etc.
- Do not provide treatment advice to colleague (you’re an anaesthetist, not a psychiatrist)
E
- If welfare of them or their patients is at risk I would discuss with a suitable senior colleague
- If refusing help and impacting patient safety –> mandatory reporting
- Consult own MDA
- Document concerns
S
- Support and monitor colleague
- Re-evaluate ongoing situation
- Give them a buddy/mentor, try to avoid isolated practice
- This may all be overseen by medical board or Council’s Impaired Registrants Program
Concern about a colleague for substance abuse/stealing opiates. What do you do?
- Direct evidence of use:
- Call for help if necessary
- Do not leave alone
- Relieve of clinical duties
- Notify head of department
- Notify duty psychiatrist and arrange escorted inpatient admission
- Notification to regulatory authority - Major Signs (injection marks, drugs/injecting equipment in non-work environment, direct observation of use, diversion or falsification of records, intoxicated/withdrawal symptoms, signing out increased quantities)
- Immediate report to senior - Circumstantial (long sleeves, blood, absenteeism, working alone, carrying syringes in clothing, impairment, irregular hours, withdrawal, mood, behaviour)
- Collect evidence
S
- Review WOASIG or local guidelines
P
- Patient safety is at risk due to impaired clinician
- Clinician’s health/reputation
I
- Collect evidence confidentially (retrospective chart review, observation)
- Ensure confidentiality
- Contact local substance use committee and/or trusted supervisor
- Collection of written evidence with senior input
- involve a colleague who has previously dealt with this situation if possible
E
- Mandatory reporting if confirmed
- Only intervene on definitive evidence. Include head of department, psychiatry, substance misuse committee, hospital exec —> intervention meeting
S
- Accompany at all times (high suicide risk)
- Inpatient rehab (voluntary vs involuntary)
- Return to work will be overseen by regulatory bodies
ETOH - inpatient admission not necessarily required. Otherwise same process.
Cardiac arrest
DRSABCD 4Hs & 4Ts CRP and attach defib Assess rhythm - Shockable --> shock, continue CPR 2 minutes, reassess. Adrenaline 1mg post second shock. Amiodarone 300mg after 3rd. Adrenaline 1mg every second loop. - Non shockable --> adrenaline + continue CPR, re-assess 2 minutes. Adrenaline 1mg every second loop During CPR - Airway adjuncts - O2 - IV access - Waveform capnography Post resus Post - ABCDE again - ECG - Treat precipitant - Temperature control
Bullying
ANZCA bullying, discrimination and sexual harassment working group report - 34% of trainees experienced or witnessed bullying in the past year
Minimal reporting due to lack of awareness on how to report, fear or retaliation or perceived lack of response
Bullying is repeated unreasonable behaviour directed towards a person or group that creases a risk to health and safety
S
- Avoid conflict in the presence of patients, any discussions should take place in a private setting
- who, what, when, where
- WHY the consultant acted in the way they did
- ANZCA and WOASIG documents
P
Patient - impairment in colleague or communication undermining patient care
- Reduced confidence in medical care if witnessed event. Ideally perpetrator should apologise to and reassure patient (may be you or other supervisor to do this)
Victim - Mental health
Perpetrator - ?underlying reason for behaviour (e.g. stress)
I
- Encourage victim to seek help
- Documentation of objective facts
Option 1 - direct approach
- Seek formal feedback from perpetrator
- Suggest that their behaviour was not appropriate
Option 2 - indirect approach
- Request assistance from supervisors (or HR) if uncomfortable approaching bully
E
- SOT, director, colleagues,
- attempt to resolve the problem amicably before making formal complaint
- Employer should investigate and coordinate resolution +/- disciplinary action
S
- Self care/support colleague
- Suggest someone close to bully checks-in on them, demonstrate understanding of bully’s situation if linked underlying issues (but don’t allow the bullying)
Media asks for a comment
- Not in a position to comment
- Direct to PR department
- make PR department aware of encounter
- Make departmental head aware of encounter
- Get feedback on handling of situation
