Kit Dumps, Checklists, & other tools to help you prepare for this important role
Step up to the head of the bed for the first time in a resuscitation, and you may feel (at long last) that you’re being given an opporunity to intubate. Even if this is partially true, there are many pitfalls in this belief. For those who are expected to be able to step up to this important position, a complex and varied set of skills beyond that of laryngoscopy are required for success. Here are just some of the many skills someone in that role must have:
- Strong communication & teamwork skills
- Skilled at rapid & focused airway assessment
- Expert at pre-oxygenation & patient preparation
- Comfortable with the principles and performance of RSI
- Skilled at the set-up & performance of laryngoscopy (DL & VL)
- Confident with the use of rescue tools: BVM, SGA, bougie, cric kit, etc.
- Knowledge of post-intubation care (vent settings, sedation, patient safety)
- Sufficient understanding of stress & performance to carry out all these tasks.
This is the challenging reality that awaits anyone stepping up to the head of the bed role, and it’s an intimidating one. Not surprisingly we all have a strong desire to find tools to tame this beast. Tools like safety checklists that can effectively assist new physicians learning the role, and help novices and experienced operators alike protect patients from medical error.
But there is also a danger in putting too much reliance on the power of the checklist when learning to feel comfortable in this position, which we will talk about later. But first here are my three simple steps for building a successful approach to the head of the bed:
- Enter with the right mental attitude
- Recall your simple cognitive framework(s)
- Employ a detailed checklist
Enter with the right mental attitude
As you enter the head of the bed, the first and perhaps most important step is solidifying the right mental attitude. Under stress the brain’s cognitive functions begin to decline. As the big picture and the thought of what’s required starts to feel overwhelming, negative thoughts can begin to intrude.
Take a deep breath and say to yourself “I’ve got this.” Remember that your team is here to help, and that you have a plan. Don’t focus on the big picture just focus on the next step. Part of understanding stress and inoculating yourself against it is acknowledging the effect it’s having on you in the moment, and knowing that you’re prepared with a plan that takes this into account.
Recall your simple cognitive framework(s)
Now that you’re there, the complexity and chaos of an emergent intubation, and our latent desire to bring that chaos under some kind of control, might tempt you into believing this is the perfect time to jump right to that intubation checklist – pulling out the laryngoscope and checking your tubes. STOP!
The most important responsibility you have at the head of the bed is not intubation but oxygenation.
You are in charge of the A in the ABCs of resuscitation, which means that your first and only priority is ensuring that your patient has adequate oxygen delivery (if you haven’t done so yet familiarize yourself with the Vortex Approach). If you didn’t have to perform a crash intubation, and have achieved and confirmed adequate oxygen delivery to your patient you have time to start preparing for intubation if necessary.
Okay, checklist now? Not yet. A checklist is indeed a valuable type of “cognitive” tool. As a guard rail for the brain, it works to prevent mistakes of order or omission during complex tasks. In a learning context, it can also be a valuable way to assist novices and help them review the necessary components of a complex procedure or action.
A checklist however has limitations. It’s not the type of cognitive tool (described well in the Triad Approach) that supports how the brain works under stress – giving you the ability to frame knowledge in a way that you can recall and deploy effectively in the fluid course of an airway emergency. Instead the checklist is there to protect you from your brain.
Before Chesley “Sully” Sullenberger took off that fateful day, I’m sure he used a checklist to avoid any human error, but when his plane was unexpectedly struck by a flock of birds, it was not a checklist that allowed him to land safely in the Hudson river, it was his ability to effectively deploy essential knowledge and skills under stress.
Another good example of what I mean in the world of airway emergencies is to compare the difference between an airway algorithm (which lives somewhere between the cognitive tool and the checklist) and the Vortex approach mentioned earlier, which employs a high acuity cognitive tool.
The strength of the high acuity cognitive tool over the checklist as the next step in building your approach to the head of the bed, is that it provides a mental framework upon which to act without dampening the strengths of the human brain: allowing for intuition, improvisation, and creativity in a crisis. Something a checklist by its very nature does not do. Airways can evolve rapidly; having the agility to jump from the checklist to the ABCs of resuscitation requires a mental framework that may include a checklist, but is not ruled by one. So don’t learn to the checklist alone or you will find yourself insufficiently prepared.
So what is my next step? After my patient’s oxygenation is confirmed and before I grab my checklist (if I haven’t already performed a crash intubation) I recall this simple phrase:
Prepare my patient, prepare my equipment, prepare my team.
It’s not a fancy graphic but this little mantra is the cognitive tool I use to begin preparing for intubation. It puts all the tasks ahead of me into three organized buckets, but allows me the fluidity to adjust my actions when needed. It’s also just the right amount of mental organzation for me to complete most items on an intubation checklist without being distracted by one.
This mantra is also nicely mirrored by most of the good intubation checklists out there, making them easy to integrate into your workflow – helping to fill in the details, and allowing an opportunity for me and the team to review everything before proceeding to the intubation procedure.
Employ a detailed checklist
I used to think there was no perfect intubation checklist out there, That was before I understood the difference between a high acuity cognitive tool and an intubation checklist. Before that, I misused them in my training, and in how I trained others – believing they were either too complex for rapid use in an airway emergency, or too simplified to function in their role as a comprehensive safety check.
But a properly used checklist is essential for preparing for intubation and managing the role of the head of the bed, and there are some really great ones our there to incorporate into your head of the bed training. So let me be clear. I use a checklist. I like checklists. Step three of building your head of the bead approach is using a checklist!
This one from EMUpdates is my favorite. It’s by far the most comprehensive and it’s constantly being improved (this is version 13!!). It provides a nice combination of a checklist within a workflow that provides helpful prompts for each check box – which also makes it a great learning tool.
Here is the link to the site and the PDF for download.
The Kit Dump (Checklist) Solution
This combination of a checklist and a visual aid is more compact the EDICT but wins point for ingenouity. The creator describes it as great for occasional intubators or physicians working in places with staff of varied experience. But its visual format is also great for teaching. This one is by KIDoc and is my favorite example of a kit dump.
Another great checklist is Scott Weingart’s slimmed down update at EMCrit This “light” version of the airway checklist mirrors the “prepare your patient, prepare your equipment, prepare team” mantra beautifully and is a slim portable design that you could practically tattoo on your forearm if you wanted to (if anyone has done this please send me a photo!)
Summary
Standing at the head of the bed is not simply about intubation. It requires a complex set of skills that have a single purpose: to prioritize oxygenation of your patient above all else. To begin building your comprehensive head of the bed approach remember these three simple steps:
- Enter with the right mental attitude
- Recall your simple cognitive framework(s)
- Employ a detailed checklist
And remember that a checklist is helpful to prevent error during intubation, but it will not give you the right attitude or mental framework to meet all the challenges you will face in reaching your primary goal.
Flipping the Head of the Bed
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