When I’m teaching airway management to my Perioperative/OR nurses, I often recount the story of what happened during one particular child’s recovery years ago. This case, involving a 2 year old child who developed respiratory depression in the recovery room, demonstrates how good communication, including the ability to challenge an authority figure, can improve patient safety and allow collaborative teamwork in a crisis management situation.
The girl was about 2 years old, 15 kg, and had just undergone a hernia repair under general anesthesia. Anesthesia was inhaled sevoforane through an LMA, with local anesthesia provided by the surgeon and 1.5 mg (0.1 mg/kg) of morphine given IV at the end prior to wake up to try to minimize any potential emergence delirium. Emergency delirium is a condition during emergence from general anesthesia where the patient exhibits severe and often combative agitation. It’s of concern because it creates a risk of injury to patient and providers.
The child was very sleepy on arrival in the recovery area. The nurse taking care of the patient was experienced, but new to our hospital, and was still on the first day of his first week of probation. He noticed that the child was breathing very shallowly and at only about 8 times a minute. The child also did not respond when he shook the child on her shoulder. Although the saturation was 99%, he was concerned. He called the float anesthesiologist in charge of the OR, which that day happened to be me.
I came to the bedside and saw that the nurse was holding the green oxygen mask on the girl’s face and was tilting the head back using the jaw thrust maneuver. The saturation was 98%. While the nurse was giving me report, I started reading the anesthetic record to see what the child had been given. The nurse softly said, in a barely audible voice, “She’s breathing awfully shallow”.
I looked down, thought I saw some chest motion, looked at the monitor and saw that the oxygen saturation was till 98%, and then went back to looking through the record. A minute passed while I was discussing options, such as getting Narcan out of the drug locker with one of the other nurses.
At this point, the first nurse looked straight at me, and spoke in a firm and neutral voice, saying “I’m concerned that this child is not breathing well. I think you need to help her breathe.”
At that point I said, “Well, then let’s do that” and I took the airway, grabbed the ambu bag and started to assist the girl’s ventilation. I hyperventilated her for several minutes while narcan was being brought to the bedside and diluted. She started to stir and then over the next couple minutes she began to breathe better on her own. Finally she woke up. We never had to give the Narcan.
What Happened Clinically?
This 2 year old clearly had had respiratory depression, most likely from the morphine. Children are very sensitive to the sedative effects of medication, especially opioids. Although 0.1 mg/kg is an acceptable dose, I often find that it’s better to start with a much lower dose in small children, such as 0.025 mg/kg to 0.05 mg/kg and titrate up as needed. I dilute the medication so it’s easy to inject such small doses. As I tell my students, it’s easy to put medicine in, it’s hard to take it back out.
Respiratory depression leads to a slower respiratory rate and shallow breathing. If the breathing is too shallow, there is inadequate alveolar ventilation. If the tidal volume is less than the dead space, then there is no alveolar ventilation.
Dead space is the portion of the respiratory system where tidal volume doesn’t participate in gas exchange. Anatomic dead space consists of the parts of the respiratory tract that are ventilated but not perfused. It consists of conducting airways such as the trachea, bronchi, and bronchioles —structures that don’t have alveoli. It’s called anatomic because it’s fixed by anatomy and doesn’t change.
About a third of each normal breath we take is anatomic dead space, which means that a third of each breath is essentially wasted. Dead space is age dependent. It’s highest in the infant at 3 ml/kg ideal body weight and is about 2 ml/kg in children and adults. An adequate tidal volume must include enough volume to also fill the dead space, otherwise not enough air enters the alveoli and the patient hypoventilates. A 15 kg child has a dead space of about 30 ml (2ml/kg), a resting tidal volume of about 105 ml (7 ml/kg) and an effective alveolar ventilation of 75 ml (105 ml – 30 ml).
Let’s say our child starts to hypoventilate and is now taking tidal volumes of 40 ml. She’s still moving 40 ml of gas in and out of her mouth and you can feel her breathing and see her chest move, even though it looks shallow. Her dead space is still 30 so now the amount of gas reaching her alveoli is 10 ml (40 ml – 30 ml). That’s not enough to get rid of CO2. It might be enough to maintain her oxygenation for a while.
Remember, oxygenation and ventilation are different. Ventilation exchanges air between the lungs and the atmosphere so that oxygen can be absorbed and carbon dioxide can be eliminated. Oxygenation is simply the addition of oxygen to the body. If you breathe a high concentration of oxygen, but don’t increase or decrease your respiratory rate, your arterial oxygen content (PaO2) will greatly increase, but your PaCO2 won’t change.
If you are providing our child with extra oxygen, she may not become hypoxic right away because enough oxygen will still reach her alveoli to maintain her oxygen saturation for a while. That’s good. But the bad news is that supplemental oxygen can sometimes mask respiratory depression. So our patient’s ventilation was poor. As a result, her carbon dioxide most likely started to rise. Hypoventilation leads to increased PaCO2 and respiratory acidosis. Acute values above 50 mmHg are significant and require treatment; values above 70 mmHg can be life-threatening.
If carbon dioxide rises into the 70–80 mmHg range, it will profoundly sedate the patient. This worsens hypoventilation, and increases carbon dioxide even more. Respiratory acidosis further depresses the patient — respiratory rate slows and the patient can stop breathing.
When I hyperventilated our child, I most likely lowered her CO2 back toward normal. I no doubt also helped remove any residual anesthetic gas from her lungs. Both would have the effect of making the patient more awake and indeed she woke up without having to reverse her narcotic.
The take home message is that even if your patient is breathing, and the oxygen saturation is good, there can still be significant hypoventilation, as well as a lower PaO2 than normal and hypoxemia. You have to reassess your patient frequently when they are semiconscious or unconscious.
What Can We Learn From The Team’s Communication?
This was textbook good communication during crisis management, which is why I often use it as a teaching example. Our nurse did something absolutely essential, and also something very difficult to do. He challenged my assumption that the child was breathing well and respectfully forced me, the leader, to reassess the situation. Challenging a leader can be very intimidating. The airline industry is full of examples of co-pilots who did not feel empowered enough to challenge the captain on such things as how much ice was on the wings or how much fuel was in the tank. Failure to challenge the assumptions of the authority figure led to serious, sometimes fatal crashes. To address this issue, the airline industry spent a great deal of time and training on improving team communication, supporting the idea that if you see something worrisome you should always say something.
Their example has spread to the medical profession. One example is the program TeamSTEPPS (1). TeamSTEPPS is an evidence based framework to optimize team performance. It’s based on 5 key principals:
- Team Structure
- Situation Monitoring
- Mutual Support
Covering all 5 principals is beyond the scope of this discussion, so we’ll concentrate on one of the skills our nurse was using — what TeamSTEPPS calls mutual support. When using this skill, team members foster a climate where it is expected that assistance will be actively sought and offered. Among other things, team members feel empowered to advocate for the patient when the team members viewpoints don’t coincide with that of the decision maker. In other words we pay attention, and if we see something that will affect patient safety or provider safety then we say something. We have each other’s backs, and that includes the leader’s.
How do You Make Suggestions To An Authority Figure
You have to assert corrective action in a calm and respectful manner:
- Make an opening
- State the concern
- State the problem (real or perceived)
- Offer a solution
- Reach an agreement on next steps
When our nurse initially expressed the concern that the patient was “breathing awfully shallow”, he used a soft, tentative voice. I did hear him, but in my initial, rather rapid assessment, I thought we were still okay and that we had time to decide on a plan. I said nothing and kept focusing on reading the record. He could have easily left it at that and stayed silent. Instead, when I did not respond he challenged me a second time. This time he was respectful, but louder, and very explicit about the fact that he was worried about the child. He clearly stated what he was concerned about: that the patient was not breathing well. And he made a recommendation for action: that I should help the patient breathe.
If the team member being challenged does not respond, it’s okay to challenge again. Use of two-challenge rule empowers all team members to stop the line if they sense or discover an essential safety breach. The team member being challenged must acknowledge that the concern has been heard.
I was impressed that a new hire, on his first day and still on probation, would feel empowered to respectfully challenge a doctor he did not know in a crisis. After the child was awake, I immediately went to the nursing supervisor for the area, who had come over to assist, and recommended that we hire the nurse permanently — which we did.
Is It Always That Easy To Challenge?
Unfortunately no. To be honest, not all doctors respond to suggestions from nurses so easily. Sometimes doctors don’t even respond well to other doctor’s suggestions in a crisis. Occasionally there is a tendency to let ego get in the way. But failure to make an observation or suggestion could potentially lead to serious or fatal consequences for your patient, or hurt a team member. How you approach this communication is important.
Don’t be confrontational. Be calm and respectful. Start your statement with words such as:
- I’m concerned!
- I’m uncomfortable!
- This is a safety issue!
Expressing concern along with the specifics of why you’re concerned immediately places the responding team member in a more receptive, and less defensive frame of mind. You’re not challenging their authority; you’re worried about something concrete related to the patient.
You can also make suggestions of actions to take. Doctors are human too and sometimes we get hyperfocused in an emergency. This can lead us to concentrate on specific details but miss the bigger picture or overlook certain basic steps that can be helpful.
In addition, you may be dealing with residents, or newly graduated providers who have less experience in dealing with a particular type of crisis than you do. For example, my sister, with over 30 years experience as an emergency room/intensive care nurse would have participated in the management of far more cardiac arrests than a physician freshly graduated from residency training. She would have a lot of valuable input during a code that could help the doctors she’s working with.
So how can you make suggestions in a non-confrontational manner? Here are some examples of suggestions that nurses have made to me over the past several years when things were not going smoothly in the OR and perioperative areas.
- Do you want me to bring the crash cart?
- Would you like me to call for additional help?
- Would you like me to get the difficult airway cart?
- I brought the tubes for Type and Cross, would you like me to send a sample.
- Shall I start another IV?
- I brought you the Crisis Management Checklist.
- I saw in the chart that the magnesium level was low, would you like me to get some from pharmacy to have available?
In this way, you are not only offering to help, you’re making specific suggestions on things you think should be done in a way that doesn’t irritate. When I’m helping another doctor during a critical event, I use the same approach. And sometimes I have to use the two-challenge rule as well.
Working collaboratively with the leader in a critical event doesn’t mean just following orders. It means functioning as a member of a highly collaborative team. Somebody has to lead. But, multiple brains allow for better, faster, and more effective problem solving.
Being able to communicate this way takes practice and I encourage you to get into the habit of using it in your everyday work, not just during crisis management.
May The Force Be With You!
Christine Whiten MD, author, Anyone Can Intubate, 5th Edition
- TeamSTEPPS Pocket Guide. AHRQ Pub. No. 14-0001-2, Dec 2013, Agency of Healthcare Research and Quality https://www.ahrq.gov/teamstepps/index.html