fiji critical care jenga
TRANSCRIPT
Critical Care Jenga in Fiji
Associate Professor Anne Creaton Fiji National University
What it feels like to provde critical care in a less developed setting& Why it feels like that
Good things come to those who believe
Better things come to those who are patient
The best things come to those who don’t give up
FaithPatiencePersistence
Outline
• Challenges for the clinician • Why Jenga • Cases • What is required to survive
What do you need to succeed?
Email from registrar wanting to spend 3 months in Fiji
Realistic Resilient Resourceful
Emotional Intelligence
replyselection criteriahow to prepare “nothing can prepare you” what do you need to succeed
Systems Clinician
Impact
What is the value of a clinican trained in a high resource environment?
RISKDysfunctional systems impact onclinician welfare, clinician performance.
Think about how you would perform in some of the scenarios that follow
Consciously Competent & Ready to Contributeenthusiastic motivatedknowledge skills & attitudes to be consultant, before commit to exam prepexperience something elsecontributemake a difference
can risk stratify chest pain in his sleepwhizz with central linesultrasound is like a 5th limbdifficult airways barely raise a sweatpray for multitraumatrain hard fight easy
recently completed a workshop on human factors
largely ignorant about the well developed systems that support his success in his usual work environment
Challenges & Building Blocks
Lets Consider critical care systems as consisting of discrete pieces or building blocks that need to fit together
The dr provides only a small part of critical care. and is a link in a chain
The gamefor those unfamiliar.. wiki :Jenga is a game of physical and mental skillPlayers take turns to remove one block at a time from a tower then balanced on top of the tower creating a less stable structureFrom Swahili “I build”
critical care jingo consists of 3 types of blocks
Scene Care
Communication
Transport Care
Hazmat
PPE
Decontamination
Retrieval
Handover
Pre-hospital Blocks
Scene caretransport carecommunication pre-hospital notificationhandoverhazmatPPEdecontaminationretrieval
WHO approach to allow policy makers
Drugs
Diagnostics
Treatment
Assessment
Triage
Flow
Equipment
Referral
Hospital Blocks
triagemedical assessmentdiagnosticstreatmentdrugsequipmentreferralpatient flow
Risk Management
Data Leadership
Audit
Recruitment
Retention
Training
Credentialing
Administration & Governance blocks
dataauditrisk managementleadership
HR: recruitment retentiontrainingcredentialing
House of Critical CareCritical Care
complex organismcritical care palace
CASES
A Ashiq 1
Nausori. CP may not get ECG. Many delayed /missed STEMI transfers. QI campaign. Ash was diagnosed awaiting t/f VT given verapamil called ED for retrieval. Defib malfunction. CWM STK. Cariogenic shock CHBvisiting team PCIRepresent 1/52 laterimplantable defib settings
Blocks Faulty defibrillator Verapamil Time sensitive transfer Access to PCI/pacing Lack of effective risk management and quality improvement
Side notes
Pacemakers Drugs
use for salbutamol tablets
Induction agents Benzodiazepines Beta blockers Amiodarone Normal saline Heparin Calcium
******Aspirin*******
When electrical cardioversion in first line for AVNRT….
“Boat Explosion”Cardiac arrest Control the resus room Delegate roles OT Blood Bank FAST Radiology Media ….......Glory.........
2
TOXIC
OLOGY
young man CPR in progress, asystolecyanosed needs intubationno trolleyonly ETT size 6.5BVM no chest rise..no ETTconsultant tells you to take it outstill no chest riseBVM is faultynew equipment is broughtsats are falling. 2nd time luckyasking for historybystander mentions boat explosion in harbour..1st you've heard of it!remember there is a trauma team processpatient 2 unconscious barely breathinganaesth to get ready for RSI3rd pt sob and agitated4th pt elevated RR but looks okjust about to induce pt 2 when wakes upconsultant says no external signs of trauma or burnsambo staggers in coughing and sob……
Side NotesCyanide spill
BlocksHazmat Decontamination PPE Communication BVM leak, ETT tube, airway trolley Diagnostics (lactate, drug levels) CN antidotes
How to Survive?
How to make meaningful change?
So Many Challenges..
What to do?
VF Arrest
Realistic Resilient Resourceful
Back to the 3 Rs: here’s an example Early defib crucialHealth facilities: AED, empower nursesPelican casesGot them through twitter
Subject: ACEM advanced trainee positions in Fiji in 2017 Dear Anne, My name is ….....and i'm an advanced ACEM trainee currently working at the Alfred Hospital in Melbourne. I'm writing - no doubt probably a bit too late in the day - to ask if you know of any opportunity for ACEM registrar positions in Fiji during 2017. My understanding of what the role would involve is currently limited to what I have read in the IEMSIG newsletters (alongside brief chats with Dr…. during shifts at work - who essentially just told me to email you) however i'd be keen to take on some combination of clinical service provision, teaching, plus or minus research/audit work if these opportunities were available. My aim would be to hopefully enjoy the work and what I imagine would be a very different set of challenges, while also getting an idea of whether this is the kind of work i'd like to continue to be involved with in the future.
Thanks for your time,
Best wishes, Here is the most recent email
Expectation Management
Realism
Resilience Resourcefulness
RRRWhen the staff don’t turn up, can’t be bothered, the patient is dying and there is no sense of urgency The equipment is missing or doesn’t workThe drugs are out of stockYou are doing CPR on the floor in the waiting room due to exit block
Are You Ready To Play Critical Care Jenga?
You function well and save lives because of the complex organism that supports youHow will you go when the organism is sick or absent?
