The ability to tactfully and effectively challenge another provider when you see a problem is key to patient safety. Challenging another provider is difficult. We all have egos we protect. You will often be called upon to stand by or to help a colleague. But what if you don’t agree with the plan? Do you say something? And if so, how? (Note: a version of this case was published in 2018 in the Anesthesiology News Annual Airway Management issue: Always Prepare for Failure:10 Rules for Approaching Difficult Intubation)

The Case:

I was called to assist in an OR by another anesthesiologist. My colleague was anesthetizing a morbidly obese man with a BMI of 50 kg/m². He wanted another set of skilled hands available in case of difficulty. He had placed a number 4 Laryngeal Mask Airway (LMA) Classic (Teleflex) airway. Intubation might be difficult for this short, noninvasive procedure and he had hoped to avoid intubation. However, he had a GlideScope in the OR in case he needed to convert to an endotracheal tube (ETT).

Although possible to ventilate through the LMA, it was difficult. The patient was breathing spontaneously but with an obstructive pattern, and tidal volumes were small. He had decided to carry out intubation by passing a fiberoptic scope down the lumen of the standard LMA. His goal was to cannulate the trachea with the fiber. He would then use the fiberoptic scope as a stent to pass a size 6 Mallinckrodt Microlaryngeal Tube (MLT) into the trachea through the LMA [1]. The MLT is longer than the standard size 6 ETT. It extends past the lumen of the classic LMA into the trachea.

He judged this to be the safer course rather than proceeding straight to the GlideScope. He reasoned:

• he had a lot of experience with this technique
• ventilation was adequate, though not optimal
• blood oxygen saturation was 100%
• it allowed spontaneous ventilation in this patient with potential difficult airway
• he had extra help in the room

We placed an endoscopy adapter on the LMA. This allowed continued ventilation. He passed the fiberoptic scope down the LMA. He cannulated the trachea with the fiber but then could not pass the ETT through the LMA. At this point, he decided to switch to an LMA Fastrach. I suggested using the GlideScope, but he was reluctant to move away from a technique that allowed ventilation.

Things Start To Go Wrong

So he removed the LMA Classic and placed the LMA Fastrach and tried ventilating. This time he could not ventilate well at all. He quickly removed the LMA Fastrach. Mask ventilation was difficult and saturation started to drop into the 80s. My colleague grabbed a number 5 LMA Classic. He placed it because he thought the larger lumen would help pass the number 6 ETT. Once again he could ventilate, but it was harder than it had been initially. Saturation only rose to 95%. He reached for the fiberoptic scope to try the combined technique again.

Time To Challenge Another Provider

At this point, I said I was uncomfortable with that plan. I said I was afraid that if we continued with this technique, we would lose the airway. I again suggested the GlideScope. If that failed, we could wake the patient and use awake intubation.

After some thought, my colleague agreed. Intubation with the GlideScope was slightly challenging. The patient’s large lingual tonsils posed difficulty. However, he succeeded on the first pass. No doubt the lingual tonsils made ventilation difficult. They also complicated the use of the fiberoptic scope through the LMA. The patient did well.

This case illustrates several important points. First, you need to always plan for failure of Plan A when facing a difficult airway. This is crucial when you choose to use an LMA in a patient with a difficult airway. Second, it’s an example of communicating during problem solving.

Plan To Prevent Airway Emergencies

We need to assess for safety whenever we are involved in any patient care. This applies even if we are NOT the primary provider. For a reminder of the key issues involved see:

• Preventing Airway Emergencies

Call for Help Early

If an unexpected airway problem occurs, you will need help and equipment quickly. Call for help early. Don’t wait until saturation plummets. Ask your team to bring the video laryngoscope. Also, have them bring the difficult airway cart. Do this as soon as you start to experience significant problems. It takes time to run to your location. If it turns out you don’t need the help, thank the responders and send them on their way. Minutes count in saving brain cells and lives, and it’s better to be safe than sorry.

When Do You Stop If Something’s Not Working?

There was nothing inherently wrong with my colleague’s plan. I suspect that each member of my department might have come up with different plans. Each could have reacted differently when faced with the same patient. In one literature report, the researchers asked 9 internationally recognized airway management experts to review a challenging airway case. They made recommendations on how they would have proceeded. Eight different plans emerged. Several of the experts ruled out some of the proposed management steps offered by their peers as too dangerous [2].

What is difficult to know is when to change to a different technique, or stop. Recognizing the potential point of no return can be very hard. This might lead to the loss of the airway. The temptation is strong to protect your ego by proving to yourself you can do this. You want to show your audience of staff members that you are skilled at performing that technique. “This should work, I’ve done it before; I will make it work.”

Time Stands Still in an Emergency

One confounding factor in deciding to abandon a technique, or even the entire intubation attempt, is unawareness of time passing. This often happens in the middle of an emergency. What seems like 1 to 2 minutes can really be 10 to 15. Force yourself to keep track of the clock. Pay attention to time passing and enlist the aide of your team to keep you on track.

How Do You Challenge Another Provider?

This case also illustrates the difficulties in questioning another provider’s decisions. TeamSTEPPS is an approach to training highly functioning teams to effectively manage care in a crisis [3]. In TeamSTEPPS, one skill involves using the Two-Challenge Rule when you feel there has been a potential breach of safety. The Two-Challenge Rule states that if your first verbal observation of a problem is not acknowledged, you should challenge. If your observation is not acted upon, then you should challenge again. If the safety issue persists, then becoming more assertive is recommended.

Don’t make it personal. Avoid words like “you’re wrong”. Don’t put the listener on the defensive. Don’t curse, but instead use “CUS” words, that is [3]:

• I am Concerned about …
• I am Uncomfortable because …
• This is a Safety issue …

It’s very difficult to challenge another provider, or indeed anyone in authority. People can get defensive when they feel they are being questioned, especially by a subordinate. The airline industry recognized this before initiating industry-wide retraining in teamwork and communication. Copilots and other flight personnel did not feel empowered to point out the mistakes they had recognized [4]. As a result, there were accident reports of airplanes crashing and flying into mountains. Planes also ran out of fuel. The airlines realized they had a culture that showed [5]:

• excessive deference to a leader;
• hesitation of subordinates to speak up; and
• reluctance to promptly question a clearly unusual or suspect event.

If a copilot facing personal death in an airplane crash can’t question the pilot, it indicates a real barrier. How easy is it, then, for a nurse, for example, to challenge a doctor?

Encourage The Freedom To Communicate

I have always tried to teach “if you see something, say something”. I would much rather have someone tell me something I already know. This is better than having them assume I know it and allow an avoidable error. This happened to me early in my career.

Case #2

In the 1990s I was a brand new, young chief of service. I was giving conscious sedation anesthesia for a hernia repair. One of the nurse anesthetists had just entered the room to see if I needed a break. He was standing off to the side. My patient complained of anxiety and I reassured him, saying that ” I will give you something to relax”. I reached back and instead of grabbing my syringe with valium, I accidentally picked up the syringe with succinylcholine. I forgot to check the label. Some mild chaos ensued as I immediately realized my mistake, gave my patient a quick dose of propofol. I then ventilated him with some nitrous oxide until he woke up and could breathe. No harm was done. and fortunately the patient did not remember anything.

However, as I was ventilating the patient, my CRNA said to me. “I never would have thought about using succinylcholine to relax someone.” My jaw dropped. I realized that my CRNA had watched me inject a ml of succinylcholine. However, he had not felt empowered to say anything to stop me, his new chief, from making that mistake.

This event made me a strong advocate to teach people to speak up. Our simulator classes emphasized this skill set. In the years that followed, I often shared a particular story. A new nurse on probation successfully challenged my airway management of an over-sedated toddler in the recovery room. The nurse pointed out that he was concerned the chest was not rising adequately with my ventilation. He did it respectfully, got my attention, and changed my management. After the event I walked over the his supervisor and told her to hire him permanently. For that full story and further discussion of TeamSTEPPS see:

• Communication In A Crisis: A Case of Respiratory Depression In A Child .

Human Error Frequently Occurs

In closed claims analyses, human error has been implicated in 80% of critical events [4]. Human error is unavoidable. Any one of us can make a bad situation worse, both by our actions and by our inaction. Yet, if we improve our skills in teamwork, leadership, and communication, we can reduce the likelihood of those errors occurring. We can also lessen the damage when they occur.

All of our staff should feel empowered enough to speak up when they see something. We need the leaders in a critical event to be open to feedback and suggestions. We need to foster a clinical environment where we feel safe sharing. Learning how to challenge another provider is part of that skill set.

May The Force Be With You!

Christine E. Whitten MD
Author : Anyone Can Intubate: A Step-By-Step Guide
&
Pediatric Airway Management: a Step-By-Step Guide

References

1. Pennant JH, Joshi GP. Intubation through the laryngeal mask airway. Anesthesiology. 1995;83(4):891-892. Comment in Tracheal intubation through the laryngeal mask airway. Anesthesiology. 1996;85(2):439.
2. Cook TM, Morgan PJ, Hersch PE. Equal and opposite expert opinion. Airway obstruction caused by a retrosternal thyroid mass: management and prospective international expert opinion. Anaesthesia. 2011;66(9):828-836.
3. Agency for Healthcare Research and Quality. Pocket guide: TeamSTEPPS. www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html.
4. Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320(7237):781-785.
5. Nance J. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, MT: Second River Healthcare Press; 2008.