RSI checklists

[NomadicMedic]

I'm on my phone, so I can't get the citations, but "deviating from the checklist" is what kills people. I recently read a fantastic book about nuclear reactor accidents. Criticality accidents are when the reactor suddenly becomes hypercritical, and "runs away" from the operator. I think we can all agree that when operating a nuclear reactor, checklists to prevent these unplanned excursions are probably a good idea, because supercritical reactors are not a good idea. At all. Ever.

In several criticality accidents, the operators, who were performing routine functions, decided to deviate from the checklist and perform operations that were not indicated. Most of the time investigators were unable to ask the operators why they perform these actions, because they were dead.

It can be assumed that the majority of the operators that control nuclear power generating stations were well-trained. Let's call them the "airway docs" of their field. They managed the criticality of the reactor every day, through normal periods and those periods that may have induced a bit of pucker.

A false sense of security, complacency and dare we say, cockiness was what the NRC determined was the cause for many of the criticality accidents. The operators were well-trained, new the procedures inside and out, had checklists to follow… And disregarded the checklists for their own actions in periods of extreme stress. The exact time when a systemized checklist would be most useful.

I don't know about you, but I'm certainly not too proud to follow a check list and mark off the boxes when I perform an RSI. And I would hope that the person who is performing then induction and intubating my mother, sister or daughter isn't either.

 

[Akulahawk]

So I guess the real distinction here comes down to semantics. Is a checklist necessarily have to be a piece of paper that you physically put tick makes next to or does can it be a mental one too. In my previous post, I was referring to a checklist as a physical, piece of printed paper where you have to read off what it says or check off certain things on it in a certain order. That to me defines the limits of airway management as each patient is different, and yet, the checklist stays the same. Medicine is not a one size fits all deal.

However, I also did say that a "real airway doc" (I'm not sure why everyone else is putting this in quotes, but I'll do it too) is very well trained and knows what he is doing. Therefore, part of that proficiency is having a mental checklist memorized and not freelancing and doing procedures willy-nilly. A real airway doctor knows the algorithm and runs a checklist in his head, but he also knows how aggressive he needs to be and when to "deviate" from the checklist.

Done right, the checklist remains the same. The operator is free to select which technique to use and which drugs, but the checklist ensures that all is in place so the operator can go from primary option, to a backup option, to a rescue option and everything is right there and immediately at hand because you went through the checklist and ensured that all was available. Physical checklists could also be used/included in documentation because then you have some written "evidence" that you had your "stuff" with you and so on.

 

[MonkeyArrow]

I'm on my phone, so I can't get the citations, but "deviating from the checklist" is what kills people.

Sorry. I should have been more clear. I too am on my phone so I will attempt to keep this brief. I didn't mean deviate from the checklist as in break policy, but more like not be restricted to manage the airway with a BVM when a ET tube is indicated. If the checklist, let's say, goes in the order of BVM, ET, SGA, cric. I feel like you would have a hard time justifying a cric as your first attempt at gaining an airway in a XYZ pt., even though it was indicated, because you didn't try a less invasive means of securing the airway which could have worked, although it probably wouldn't have. This problem doesn't really exist without checklists, you acted based on your judgement and training providing care for your patients individual condition. However, a checklist, without deviating from it, I feel would force you to try airways that probably will not work. Damned if you do, damned if you don't. If you do, your not providing the optimal level of care to your pt. If you don't, you get grilled for why you deviated from the checklist.

Of corse, this could also be a misunderstanding in our definitions of a checklist- supplies gathered vs. airway mgmt. algorithm like checklist

 

[CANMAN]

This whole aviation : anesthesia thing is really overdone. There are some interesting conceptual similarities, I agree, but flying a plane and sleeping a patient are not the same thing.

I sat in the left seat for many years with many different pilots, and I've never seen a checklist used during or immediately before takeoff, aside from checking the gauges just prior to pulling power, which is analogous to checking the monitor just prior to pushing induction drugs. The actual checklists are used earlier, during the pre-flight phase, which is analogous to my use of a mnemonic during room setup.

My program uses a checklist just prior to pulling power for a flight... It's a pilot vs. crew challenge.

End of the day:
-I think checklist have their place for use in airway management/RSI for field EMS provider
-I am required to use one per my employer so we do, and I RSI on the regular with CRNA's who have to run through the same checklist as me regardless of their higher level of training or daily practice.
-Do I think running though a checklist makes you less of a provider, or can you evaluate said provider's knowledge because they use a checklist...NO