ACCS learning outcome: Manage patients with organ dysfunction and failure

 

ACCS learning outcome: Manage patients with organ dysfunction and failure

Managing Organ Dysfunction and Failure: A Guide for ACCS Trainees

Executive Summary

The effective management of organ dysfunction and failure is a cornerstone of Emergency and Critical Care Medicine. This briefing document outlines the essential knowledge and procedural steps for ACCS trainees to achieve competence and excel in this critical domain, corresponding to RCEM curriculum code ACCS LO 3 / SLO 1.

Key takeaways include the imperative to recognize impending organ failure before physiological decompensation by looking beyond vital signs and utilizing tools like NEWS2 and lactate trends. A structured, critical-care-focused Airway, Breathing, Circulation, Disability, Exposure (A-E) assessment is paramount. This involves anticipating the need for advanced airway management, differentiating respiratory failure types, defining shock states with the aid of Point of Care Ultrasound (POCUS), and initiating neuroprotective measures.

Initial management focuses on timely organ support. Cardiovascular support requires judicious fluid challenges with balanced crystalloids, followed by the early initiation of peripheral vasopressors to maintain a Mean Arterial Pressure (MAP) > 65mmHg. Respiratory support involves escalating from standard oxygen to High-Flow Nasal Oxygen (HFNO) or Non-Invasive Ventilation (NIV) where appropriate, with a low threshold for recognizing treatment failure. Renal protection is achieved through strict fluid balance, maintaining perfusion, and ceasing nephrotoxic medications.

Excellence in this area transcends basic management; it involves advanced physiological reasoning, such as understanding fluid responsiveness versus tolerance and calculating the Shock Index. Furthermore, superior performance is demonstrated through strong team leadership, employing closed-loop communication, developing a shared mental model, and making timely, appropriate decisions regarding escalation to Critical Care or establishing a ceiling of care.

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Introduction

The ability to recognize, stabilize, and manage patients presenting with organ dysfunction is a fundamental requirement for trainees in Acute Care Common Stem (ACCS) and Emergency Medicine. This learning outcome demands more than a routine assessment; it requires a deep understanding of pathophysiology, the skills to initiate organ support, and the nuanced decision-making involved in escalating care to the Intensive Care Unit (ICU). This guide provides a structured approach to developing these capabilities, from initial assessment to advanced management strategies and portfolio development.

Recognition and Systematic Clinical Assessment

The first and most critical step in managing organ failure is its early recognition, often before the patient exhibits overt signs of decompensation.

Identifying the 'At-Risk' Patient

Physiological compensation can effectively mask profound underlying organ dysfunction, leading to a sudden and catastrophic decline known as the "physiological cliff." Therefore, assessment must go beyond simple vital signs.

• Early Warning Scores: The National Early Warning Score (NEWS2) should be used to track physiological trends over time. It serves as a crucial trigger for review, not as a standalone diagnostic tool (1).
• Biochemical Markers: Serum lactate is a key surrogate marker for tissue hypoperfusion. A rising lactate level, particularly in a patient undergoing resuscitation, is a significant indicator of ongoing microvascular failure and inadequate resuscitation.

The Structured A-E Assessment: A Critical Care Focus

The standard A-E assessment must be adapted with a critical care mindset to identify and pre-empt organ failure.

• Airway: Assess for patency, protection, and the potential for future deterioration.
  • Excellence Point: Anticipate the need for Rapid Sequence Induction (RSI) early. If a patient shows signs of tiring, has a dropping Glasgow Coma Scale (GCS), or is failing to protect their airway, an immediate call to Anaesthetics/ICU is warranted.
• Breathing: Differentiate between Type 1 (Hypoxic) and Type 2 (Hypercapnic) respiratory failure to guide therapy.
  • Intervention: Promptly escalate respiratory support from a non-rebreather mask to High Flow Nasal Oxygen (HFNO) or Non-Invasive Ventilation (NIV) when indicated (2).
• Circulation: The primary goal is to define the shock state. Classify the shock as Distributive, Cardiogenic, Hypovolaemic, or Obstructive to direct treatment.
  • Excellence Point: Utilize Point of Care Ultrasound (POCUS) to dynamically assess fluid status (e.g., IVC diameter and collapsibility) and cardiac contractility. This prevents the harm associated with administering large fluid volumes to a patient with a failing heart (3).
• Disability: Perform a rapid neurological assessment, including checking blood glucose and pupillary response.
  • Intervention: In patients with brain injuries, institute neuroprotective measures by maintaining normoglycaemia and avoiding pyrexia.
• Exposure: Conduct a full top-to-toe examination to identify potential sources of sepsis (e.g., skin infections, lines), rashes suggestive of specific pathologies, or evidence of trauma.

Step-by-Step Management and Organ Support

Demonstrating competence requires the ability to safely and effectively initiate organ support in the Emergency Department.

Step 1: Cardiovascular Support

While fluid resuscitation is the initial step, it must be administered cautiously to avoid the significant harm associated with fluid overload.

1. Fluid Challenge: Administer a bolus of 250-500ml of a balanced crystalloid solution (e.g., Plasmalyte, Hartmann’s). Systematically assess the patient's response by monitoring blood pressure, heart rate, capillary refill time, and urine output.
2. Vasopressor Initiation: If hypotension persists after initial fluid resuscitation, vasopressors should be started early to restore organ perfusion. The target is a Mean Arterial Pressure (MAP) of >65mmHg (4).
   • Medication: Peripheral vasopressors such as Metaraminol or a dilute Noradrenaline infusion can be used.
   • Safety Precaution: Administration requires a patent, large-bore cannula in a large, proximal vein. The site must be checked frequently for any signs of extravasation.

Step 2: Respiratory Support

1. Oxygen Saturation Targets: Aim for SpO2 of 94-98% in most patients. For patients at risk of hypercapnic respiratory failure (e.g., COPD), the target should be 88-92%.
2. High Flow Nasal Oxygen (HFNO): This is an excellent intervention for Type 1 respiratory failure (e.g., pneumonia). HFNO delivers a high flow of humidified, heated oxygen, which provides a degree of Positive End-Expiratory Pressure (PEEP) and reduces anatomical dead space (2).
3. Non-Invasive Ventilation (NIV):
   • CPAP: Continuous Positive Airway Pressure is the first-line treatment for acute cardiogenic pulmonary oedema.
   • BiPAP: Bilevel Positive Airway Pressure is the first-line treatment for exacerbations of COPD with respiratory acidosis.
   • Excellence Point: Recognize NIV failure early. Signs of failure include patient agitation, significant air leak, or a failure of the pH to improve after one hour of therapy. If failure is recognized, plans for definitive airway management (intubation) must be made immediately.

Step 3: Renal Protection

Acute Kidney Injury (AKI) is a common complication of critical illness and is independently associated with increased mortality.

1. Monitoring: An indwelling urinary catheter is mandatory for strict fluid balance monitoring.
2. Perfusion: Maintain adequate renal perfusion pressure by ensuring the MAP remains >65mmHg.
3. Medication Review: Stop all nephrotoxic drugs, including ACE inhibitors, NSAIDs, and certain antibiotics like Gentamicin.
4. Managing Complications: Treat hyperkalaemia immediately. Administer intravenous Calcium Gluconate for cardiac membrane stabilization, followed by an Insulin/Dextrose infusion to shift potassium intracellularly.

Strategies for Excelling in Practice

Moving from competence to excellence involves a deeper understanding of physiology, team dynamics, and system-level management.

Advanced Physiological Reasoning

• Fluid Responsiveness vs. Fluid Tolerance: A key concept is that while a patient may be "fluid responsive" (i.e., their stroke volume increases with a fluid bolus), this does not automatically mean they require more fluid. Additional fluid should only be given if there is concurrent clinical evidence of hypoperfusion.
• Shock Index (SI): Calculate the SI by dividing the Heart Rate by the Systolic Blood Pressure (HR/SBP). An SI greater than 0.9 is a strong indicator of significant shock, even if the blood pressure appears deceptively normal (5).

Human Factors and Team Leadership

• Closed-Loop Communication: When leading a resuscitation, ensure all instructions are heard, understood, and actioned. The team member should repeat the instruction back, and the leader should receive confirmation once the task is complete.
• Shared Mental Model: Verbalize the clinical picture, the team's actions, and the treatment goals. For example: "This is a 65-year-old with septic shock. We have given 2L of fluid and are starting Metaraminol. The target MAP is 65." This ensures the entire team is aligned.

Appropriate Escalation and De-escalation

• Ceiling of Care: Initiate discussions about the appropriate level of intervention and potential "ceiling of care" early in the patient's journey, involving patients and relatives where possible. Excellence includes knowing when resuscitation is not appropriate.
• ICU Consultation: Consult the Intensive Care team early. Present the case clearly and concisely using a structured handover tool like SBAR (Situation, Background, Assessment, Recommendation).
• Definitive Care: Do not delay the patient's transfer to definitive care, whether that is the cardiac catheterization lab, the operating theatre, or the ICU.

Achieving the Learning Outcome: Portfolio Evidence

To demonstrate achievement of this ACCS learning outcome, trainees must provide robust evidence within their ePortfolio.

Expected Capabilities and Descriptors

Trainees are expected to demonstrate the ability to:

• Recognise, assess, and initiate management for acutely ill adults with single or multiple organ failure.
• Recognise and manage sepsis, employing local infection control policies.
• Safely perform invasive procedures for cardiovascular, renal, and respiratory support.
• Utilise and interpret laboratory and imaging investigations.
• Manage ongoing medical needs and organ support, including holistic care for patients and relatives.
• Recognise the limitations of intensive care and apply appropriate admission criteria.
• Plan and communicate patient discharge from intensive care effectively.
• Support end-of-life care within the ICU environment.
• Understand the role of transplant services and the principles of brain-stem death testing.
• Support staff outside the ICU in the early detection of deteriorating patients.

Generating Portfolio Evidence

Evidence to inform entrustment decisions can be gathered through various workplace-based assessments and activities:

• Case-based Discussion (CbD): Discuss a complex case, such as septic shock or diabetic ketoacidosis, focusing on the rationale for fluid management strategies and choices of vasoactive drugs.
• Mini-Clinical Evaluation Exercise (Mini-CEX): Arrange for a consultant to directly observe the leadership of a resuscitation case or the practical skill of setting up and managing NIV.
• Reflection: Provide written reflections on challenging cases. Examples include a difficult communication with the ICU team or a case where a decision was made for palliative care.
• Other Evidence: Multi-Source Feedback (MSF) and the Multi-Consultant Report (MCR) will also contribute to the overall assessment.
• RCEMLearning Resources: Utilize modules, Single Best Answer (SBA) questions, and Short Answer Questions (SAQ) from the RCEMLearning platform relevant to this learning outcome. Certificates of completion are automatically added to the CPD Diary and provide excellent evidence of engagement.

References

1. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Updated report of a working party. London: RCP; 2017.
2. Rochwerg B, Einav S, Chaudhuri D, Mancebo J, Mauri T, Helviz Y, et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 2020;46(12):2226-2237.
3. Working Group on Ultrasound in Acute Care Medicine. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591.
4. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
5. Allgöwer M, Burri C. Shock index. Dtsch Med Wochenschr. 1967;92(43):1947-1950.

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Achieving Mastery in RCEM Specialty Learning Outcome 7

Executive Summary

Specialty Learning Outcome 7 (SLO 7), "Deal with complex and challenging situations in the workplace," is a continuous and mandatory component of Royal College of Emergency Medicine (RCEM) training, representing the pinnacle of professional competence for an Emergency Physician [1, 2]. Mastery of this outcome signifies a transition from a clinical proceduralist to an autonomous leader capable of managing the multifaceted challenges inherent to the Emergency Department (ED). This requires a demonstrable integration of clinical excellence with robust professionalism, advanced communication, ethical acumen, and systemic leadership [2, 3].

The core requirement for mastery, particularly at Higher Training levels (Entrustment Levels 3 and 4), is the ability to manage complex clinical, interpersonal, and systemic challenges with no supervisor involvement [4]. This autonomy must be evidenced through consistent, high-quality performance in four key domains:

1. Advanced Communication and Conflict Resolution: Expertly de-escalating patient aggression, navigating high-stakes professional disagreements, and structuring difficult conversations (e.g., breaking bad news, managing complaints) using established frameworks [4, 12].
2. Non-Technical Skills (NTS) and Crisis Management: Systematically applying NTS, including Arousal Management to control personal stress responses and team cognitive load. Utilizing practical mnemonics and frameworks like 5S (Self, Staff, Stuff, Space, Safety) for preparation and LIPS (Label, Important Points, Priorities, Strategy) for situation reports enhances team performance in crises [10, 11].
3. Ethical Acumen and Legal Governance: Applying structured ethical frameworks, such as the Four Principle Approach (Autonomy, Beneficence, Non-maleficence, Justice), to navigate bedside dilemmas involving consent, capacity, triage, and professional misconduct, all while operating within UK legal parameters [4, 7].
4. Systemic Leadership and Flow Management: Moving beyond individual patient care to manage departmental crowding and patient flow at a macro-level. This involves using data, implementing evidence-based process improvements, and demonstrating Macro-Situational Awareness to drive system-wide change [2, 8, 22].

Demonstrating mastery for the Annual Review of Competence Progression (ARCP) requires strategic evidence generation. High-quality reflections on critical incidents using models like "What? So What? Now What?", detailed Extended Supervised Learning Episodes (ESLEs) capturing autonomous leadership, and Multi-Source Feedback (MSF) from external colleagues are essential [4, 6, 26]. Engagement in structured debriefing, both hot (e.g., STOP5) and cold (e.g., TRiM), provides further evidence of a commitment to team resilience and institutional learning [31].

1. Understanding RCEM Specialty Learning Outcome 7

1.1 Definition and Strategic Significance

SLO 7 is an outcome-based requirement that describes the behaviours and performance expected of an Emergency Physician upon completion of training [3]. It addresses the unpredictability of the ED environment by focusing on non-clinical challenges, including:

• Safe management of aggressive, distressed, or vulnerable patients [2].
• Sensitive handling of ethical dilemmas and end-of-life discussions [2].
• Balancing clinical workload, risk, and patient flow during departmental crowding [2].
• Maintaining professionalism and composure in high-pressure scenarios [2].

This SLO is the primary domain for demonstrating several General Medical Council (GMC) Generic Professional Capabilities (GPCs), specifically professional values (Domain 1), leadership (Domain 5), patient safety and quality improvement (Domain 6), and safeguarding (Domain 7) [3, 4]. Mastery requires a fundamental shift from a purely clinical focus to that of a leader managing complex systems and mitigating professional risk [4, 5].

1.2 Progressive Entrustment: Defining Mastery

The RCEM curriculum outlines a clear progression of entrustment. While intermediate trainees are expected to manage difficult interactions with supervisor support available from home, Higher Training trainees (ST4–ST6) must demonstrate the autonomy characteristic of Entrustment Levels 3 and 4 [4, 6].

The defining marker of mastery is the ability to manage complex and challenging situations with no supervisor involvement [4]. This requires expert communication skills and independent ownership of clinical risk and conflict resolution [4, 7].

Table 1: Progression in Capability Descriptors for RCEM SLO 7 Mastery

Key Capability Domain	Intermediate Training (Entrustment Level 2/3)	Higher Training (Entrustment Level 4: Mastery)
Challenging Interactions	Able to work effectively with angry/distressed patients and negotiate troubling interactions, with consultant support available from home [4].	Possesses expert communication skills to negotiate and manage complicated or troubling interactions autonomously [4].
Professional Conduct	Behaves professionally with colleagues and external teams, recognizing the effect of stress and fatigue [4].	Sustains professional behavior consistently, working professionally and effectively with internal and external bodies without supervisor intervention [4].
System Management	Understands departmental stress points and supports colleagues in challenging circumstances [4].	Balances clinical workload, risk, and patient flow during extreme crowding using complex managerial interventions [2, 8].
ARCP Requirement	Entrustment Level 3 (Managing with support from home) [6].	Entrustment Level 4 (Managing any complex situation without supervision) [4, 6].

2. Core Competencies for Mastery

2.1 Non-Technical Skills (NTS) and Crisis Resource Management

Mastery of SLO 7 depends on the systematic development of advanced NTS, which include supervision, teamwork, decision-making, and situation awareness [9].

2.1.1 Arousal Management and Self-Care

Arousal Management involves regulating one's own stress and fear response, as well as managing these responses in others [11]. The inability to manage personal stress manifests as novice behaviours like "freezing," tremor, or negative self-talk, which can escalate patient distress or team conflict [11]. Mastery involves internalizing self-regulation techniques such as breathing exercises, mental rehearsal, and positive self-talk [11]. The I'M SAFE mnemonic is a tool for ensuring personal preparedness for work-related stressors.

2.1.2 Team Preparation and Situational Awareness

Effective team leadership begins before the patient arrives. The resuscitation effort starts with the pre-alert, and this time should be used for preparation.

• Preparation Framework (5S): A preferred approach is the Self / Staff / Stuff / Space / Safety model. This ensures personal readiness, correct team composition and skills, availability of equipment and drugs, appropriate environmental setup, and safety considerations (e.g., security) are all addressed proactively.
• Situation Report (Sit Rep): Once the team is assembled, a Sit Rep is vital for establishing a shared mental model. The LIPS mnemonic provides a structure:
  • Label the situation (e.g., "Critically ill hemorrhagic shock").
  • Important Points/findings emphasised (e.g., "No IV access").
  • Priorities (e.g., "IO access, transfuse blood, transfer to OT").
  • Strategy (Assign roles with names, use closed-loop communication, and specify timeframes). A "10 every 10" update (a 10-second update every 10 minutes) can help maintain this shared model.

The STEP UPS mnemonic provides a comprehensive framework for managing an entire ED shift and can be used for analysis in debriefs or exams. It covers: Self, Team, Environment, Patient, Updates, Priorities, and System.

2.2 Advanced Communication and Conflict Resolution

2.2.1 Managing Aggressive and Distressed Patients

A core mandate of SLO 7 is the safe management of aggression [2]. This begins with proactive risk assessment using ED-specific tools like STAMP or the Assessment, Behavioral indicators, and Conversation (ABC) framework [12]. The goal is to identify warning signs and use calm, thoughtful communication to de-escalate the situation before violence occurs [12, 13].

However, clinicians must also recognise definitive danger signs that indicate a physical attack is imminent. At this point, the priority shifts to personal safety, requiring withdrawal or preparation for physical intervention [13]. If PMVA (Prevention & Management of Violence & Aggression) protocols are initiated, staff have an ethical duty to continue employing de-escalation techniques throughout the physical intervention to minimise harm, thereby upholding the principle of Non-maleficence [7, 12].

2.2.2 Navigating Professional Conflict

Inter-professional conflict often stems from systemic pressures like heavy workloads, stress, and organisational problems, rather than just personality clashes [14]. A physician demonstrating mastery reframes these conflicts as opportunities for Quality Improvement (QI) projects, addressing the root cause (e.g., flawed communication pathways) and linking SLO 7 to patient safety improvements (GMC Domain 6) [4, 17].

A mindfulness exercise for managing in-the-moment conflict is the WTF to WTF method, which helps control feelings and work through disagreements.

2.2.3 Frameworks for Difficult Conversations

Structured approaches are essential for managing difficult conversations confidently and effectively.

• Breaking Bad News (SPIKES QID): An adaptation of the SPIKES model.
  • Setting & Set stage
  • Perception (Gather before you give)
  • Information (Ask if they want more details)
  • Knowledge (Chunk and check)
  • Empathy & Emotions (Use the NURSE acronym)
  • Summary & Strategy
  • QID: Questions? Information? Documentation?
• Demonstrating Empathy (NURSE):
  • Name the emotion.
  • Understand the driver behind the emotion.
  • Respect, praise, and appreciate.
  • Supportive statements.
  • Explore the story.
• Informed Consent (CONSENTS QID):
  • Condition, Options, Name of procedure, Side effects, Extra procedures, Named person, Training/trial, Summary.
  • QID: Questions? Information? Documentation?
• Managing Complaints (Doc ANSR): The core principles are senior staff involvement, documentation, and open disclosure. The process involves: 1. Ensure patient safety; 2. Apologise (an expression of empathy, not an admission of fault); 3. Notify relevant parties; 4. Search/Investigate; 5. Respond both externally and internally (e.g., via QI).

2.3 Ethical Acumen and Legal Frameworks

Ethical decision-making is a core skill-based competency in Emergency Medicine [7]. The objective is to move from emotional reactions to structured, rational, and defensible arguments [7].

2.3.1 Bedside Ethical Framework

The Four Principle Approach is a simple, robust, and flexible model for bedside ethical analysis [7, 19].

Table 2: The Four Principle Approach in the ED

Ethical Principle	Working Definition (Obligation)	SLO 7 Clinical Application in the ED
Autonomy	Respect the decision-making capacities of persons [7].	Managing refusal of life-saving treatment; executing complex capacity assessments; respecting patient wishes despite clinical disagreement [19].
Beneficence	Provide benefits and balance benefits against risks [7].	Ensuring timely, life-saving care; actively intervening to promote optimal outcomes.
Non-maleficence	Avoid causing harm ('primum non nocere') [7].	Avoiding unwarranted investigations or futile care; ensuring minimal harm during restraint protocols [7, 12].
Justice	Fairness in the distribution of benefits and risks [7].	Ethical triage during crowding; balancing needs of the worst-off against the greatest number; resolving family disputes over treatment [18, 20].

2.3.2 High-Stakes Dilemmas

Mastery requires navigating complex scenarios such as:

• Triage and Crowding: Functionally rationing scarce resources (staff, beds, diagnostics) based on principles of utilitarianism (greatest good for the greatest number) or social justice (prioritising the worst off) [7, 18].
• Consent and Capacity: Applying legal frameworks like the Mental Capacity Act to complex situations, including end-of-life discussions [1, 2].
• Professional Misconduct: Prioritizing patient safety over collegial loyalty when suspecting a colleague is impaired or has acted unethically, and following GMC guidelines for escalation [4, 7, 20].

Clinicians must be aware of specific legislation, including the Mental Health Act, Mental Capacity Act, Children's Act, Data Protection Act, and principles from the Caldicott Report.

2.4 Systemic Leadership and ED Flow Management

SLO 7 elevates the physician's role to macro-level systems management [2]. This involves leveraging data analytics (e.g., flow|ER software), implementing evidence-based process improvements (e.g., doctor triage, rapid assessment, POCT), and applying management science (e.g., Lean, Six Sigma) to reduce variability and improve flow [8, 22, 23].

Mastery requires working effectively with bodies outside the ED [4]. This is demonstrated by possessing Macro-Situational Awareness—the ability to monitor the entire hospital's capacity and anticipate system-wide failure points—and applying Adaptive Expertise to lead system-level changes, such as championing alternatives to admission like SDEC pathways and virtual wards [11, 22, 24].

3. Evidencing Mastery for ARCP

The RCEM curriculum is outcome-based, requiring trainees to provide sufficient evidence in their ePortfolio to support entrustment decisions [3].

3.1 Strategic Evidence Generation

For Higher Training, mandatory annual evidence includes an Educational Supervisor Report (ESR), one Multi-Source Feedback (MSF), and a minimum of three Extended Supervised Learning Episodes (ESLEs) [6]. All documentation must be explicitly tagged to SLO 7 [3, 4].

• ESLEs are ideal for capturing complex leadership, such as managing a chaotic shift, mediating a transfer disagreement, or leading a high-stakes ethical discussion [25].
• MSF must include feedback from a satisfactory range of external colleagues (e.g., Ward Sisters, Mental Health Liaison staff) to evidence the capability of working effectively with those outside the ED [4, 6].

Table 3: Evidence Requirements for SLO 7 Mastery at Higher Training

Evidence Type	Minimum Requirement (Annual)	SLO 7 Focus
Educational Supervisor Report (ESR)	One per training year [6].	Confirmation of Entrustment Level 3 or 4; commentary on ethical judgment, risk management, and system leadership.
Extended Supervised Learning Episodes (ESLEs)	Minimum three per year [6].	Documentation of managing complex ethical cases, severe conflict scenarios, system management during crowding, or demonstrating Adaptive Expertise [4].
Multi-Source Feedback (MSF)	Minimum one per year [6].	Demonstrating professional behavior and effective teamwork with diverse internal and external colleagues [4].
High-Quality Reflection	Multiple critical reflections tagged to SLO 7 [4].	Detailed critical analysis of incidents leading to documented behavioral or attitude change [21, 26].
Simulated Practice/Training	Documented evidence of participation [4].	Assessment of NTS performance (e.g., arousal management) in simulated challenging encounters [11].

3.2 The Role of Critical Reflection

High-quality reflection is a prerequisite for professional competence [5, 27]. The "What? So What? Now What?" model is a powerful tool for moving beyond simple description to deep analysis [26].

1. What? Describe the incident, your role, and your initial reactions.
2. So What? Analyze the event, connecting theory (ethical frameworks, NTS concepts) to your actions to identify core problems.
3. Now What? Articulate what was learned and how it will change future behavior.

True mastery requires reaching the level of Critical Reflection, which involves questioning one's own deeply-held assumptions, beliefs, and knowledge [5, 26].

3.3 Structured Debriefing and Simulation

Simulation provides a safe environment to practice NTS and manage challenging scenarios [4, 30]. The learning from simulation and real-world critical incidents is maximized through structured debriefing.

• Hot Debriefing: Conducted immediately after an event to diffuse emotion, review facts, and identify learning points. Departmental tools like TAKE STOCK provide a structure for this process and can trigger QI initiatives [29, 31].
• Debriefing with Good Judgment: This advanced technique uses an advocacy-inquiry method to explore the cognitive frames—the Knowledge, Assumptions, and Feelings (NAFs)—that drove a person's actions. This fosters a shared understanding of decision-making processes and avoids a "shame-and-blame" culture.
• Cold Debriefing and TRiM: For incidents with significant emotional or traumatic impact, a "cold" debrief may be required later. TRiM (Trauma Risk Management) is a peer-support system designed to aid staff recovery after such events.

4. Conclusion and Ongoing Professional Development

Mastery of RCEM SLO 7 is the hallmark of a mature Emergency Physician, signifying the successful integration of professionalism, ethical judgment, leadership, and crisis management [4]. It confirms the physician's capacity for autonomous practice in the most demanding circumstances. This is achieved not just through clinical knowledge, but through demonstrable behavioural change rooted in critical reflection and highly developed non-technical skills [5, 11].

This competence must be sustained beyond the Certificate of Completion of Training (CCT) through a commitment to lifelong learning. Continued engagement with advanced leadership training, such as the RCEM leadership programme or the Emergency Department Directors Academy (EDDA), is vital for developing the macro-system capabilities needed to influence institutional culture and improve patient flow [4, 32]. The ultimate application of SLO 7 mastery is mentorship: modeling professional conduct, promoting psychological safety, and fostering a departmental culture that values critical reflection and structured debriefing to build a resilient and ethically sound team [17].

References

1. Specialty Learning Outcomes (SLOs) [Internet]. RCEMCurriculum. [cited 2024 May 20]. Available from: https://rcemcurriculum.co.uk/specialty-learning-outcomes-slos/
2. RCEM SLOs Explained: The Key to Mastering Emergency Medicine [Internet]. EM Learning Centre. [cited 2024 May 20]. Available from: https://www.emlearningcentre.com/blog/rcem-slos-explained-the-key-to-mastering-emergency-medicine
3. RCEM Curriculum - Further guidance on Generic SLO [Internet]. AWSEM. [cited 2024 May 20]. Available from: https://awsem.co.uk/wp-content/uploads/2021/07/Appendix-3-Generic-SLO-Curriculum-Supporting-Material.pdf
4. SLO 7 - Deal with complex or challenging situations in the workplace [Internet]. RCEMCurriculum. [cited 2024 May 20]. Available from: https://rcemcurriculum.co.uk/deal-with-complex-situations-on-the-shop-floor/
5. Aronson L. Reflection in medicine: Models and application. Med Teach. 2011;33(3):201-5.
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7. Vincent A, Creteur J. 'MORAL balance' decision-making in critical care. Crit Care. 2021 Jan 12;25(1):21.
8. Emergency Department Crowding: High Impact Solutions [Internet]. ACEP. [cited 2024 May 20]. Available from: https://www.acep.org/siteassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf
9. The assessment of non-technical skills in the emergency department. Emerg Med J. 2010;27(Suppl 1):A2.3.
10. A guide to non-technical skills in emergency management [Internet]. ResearchGate. [cited 2024 May 20]. Available from: https://www.researchgate.net/publication/359519342_A_guide_to_non-technical_skills_in_emergency_management
11. Zauher M, Muhr T, Praxmarer S, et al. A review of tools and methods in the teaching and assessment of nontechnical skills in emergency medicine training. J Educ Eval Health Prof. 2023;20:33.
12. Downey LV, Zun LS, Gonzales SJ. Management of the aggressive emergency department patient: non-pharmacological perspectives and evidence base. J Emerg Med. 2019;57(5):619-27.
13. Violent Behaviour in the ED [Internet]. RCEMLearning. [cited 2024 May 20]. Available from: https://www.rcemlearning.co.uk/reference/violent-behaviour-in-the-ed/
14. Conflict in the Workplace [Internet]. Health Education England. [cited 2024 May 20]. Available from: https://london.hee.nhs.uk/sites/default/files/conflict.pdf
15. Conflict Resolution eLearning Course [Internet]. Skills for Health. [cited 2024 May 20]. Available from: https://skillsforhealth.learnspace.org/shop/conflict-resolution
16. NHS Conflict Resolution Training Courses [Internet]. IKON Training. [cited 2024 May 20]. Available from: https://ikontraining.co.uk/courses/nhs/conflict-resolution/
17. Nursing Conflict Scenario Examples [Internet]. Conflict Resolution Training. [cited 2024 May 20]. Available from: https://conflict-resolution-training.com/blog/nursing-conflict-scenario-examples/
18. Ethical dilemmas in Emergency Medicine 4: The ethics of triage [Internet]. St.Emlyn's. [cited 2024 May 20]. Available from: https://www.stemlynsblog.org/ethical-dilemmas-emergency-medicine-part-4-triage-basically-rationing-healthcare/
19. Ethics in Health Care: Improving Patient Outcomes [Internet]. Tulane University School of Public Health and Tropical Medicine. [cited 2024 May 20]. Available from: https://publichealth.tulane.edu/blog/ethics-in-healthcare/
20. Ethical Scenarios in NHS Interviews [Internet]. BDI Resourcing. [cited 2024 May 20]. Available from: https://www.bdiresourcing.com/img-media-hub/blog/ethical-scenarios-in-nhs-interviews/
21. Chin-Yee B, Bidiscombe M, Warmington A, et al. Reflection-Based Learning for Professional Ethical Formation. AMA J Ethics. 2017 Apr 1;19(4):391-7.
22. Reducing emergency department crowding through predictive data analytics – flow|ER [Internet]. The Health Foundation. [cited 2024 May 20]. Available from: https://www.health.org.uk/funding-and-fellowships/projects/reducing-emergency-department-crowding-through-predictive-data
23. Sanchez M, Smally AJ, Grant RJ, et al. Improving emergency department patient flow. Ann Emerg Med. 2016 Oct;68(4):465-71.
24. Urgent and emergency care acute patient flow [Internet]. NHS England. [cited 2024 May 20]. Available from: https://www.england.nhs.uk/long-read/urgent-and-emergency-care-acute-patient-flow/
25. Rough Guide to Curriculum [Internet]. UK Foundation Programme. [cited 2024 May 20]. Available from: https://foundationprogramme.nhs.uk/wp-content/uploads/sites/2/2024/05/Rough-Guide-to-Curriculum.doc-FINAL.pdf
26. Critical Reflection [Internet]. Writing and Communication Centre, University of Waterloo. [cited 2024 May 20]. Available from: https://uwaterloo.ca/writing-and-communication-centre/critical-reflection
27. Examples of Reflective Practice [Video]. YouTube; 2018. Available from: https://www.youtube.com/watch?v=qQJ4gupvr-27
28. Reflecting on critical incidents [Internet]. Student Academic Success, Monash University. [cited 2024 May 20]. Available from: https://www.monash.edu/student-academic-success/excel-at-writing/annotated-assessment-samples/medicine-nursing-and-health-sciences/mnhs-reflective-writing-and-critical-incidents/four-tips-for-reflecting-on-critical-incidents
29. Raemer DB, Anderson M. Debriefing Techniques Utilized in Medical Simulation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546660/
30. Simulation Scenarios [Internet]. AORN. [cited 2024 May 20]. Available from: https://www.aorn.org/education/staff-development/simulation-scenarios
31. Walker CA, McGregor L, Taylor C, et al. Promoting hot debriefing in an emergency department. BMJ Open Qual. 2020;9(3):e000913.
32. Emergency Department Directors Academy (EDDA) [Internet]. ACEP. [cited 2024 May 20]. Available from: https://www.acep.org/edda

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Explainer document on how to achieve ACCS Learning outcome: Provide safe basic anaesthetic care including sedation

 

ACCS Learning outcome: Provide safe basic anaesthetic care including sedation

Mastering Safe Basic Anaesthetic Care and Procedural Sedation

Executive Summary

This briefing document provides a comprehensive guide for Acute Care Common Stem (ACCS) trainees in Emergency Medicine to achieve excellence in the learning outcome of providing safe basic anaesthetic care and procedural sedation. Mastery extends beyond pharmacology to encompass meticulous preparation, environmental optimization, airway stewardship, and human factors. Excellence is defined by proactive preparation, creating a safe environment before the patient is present.

Key principles for safe practice include a profound understanding of sedative agents (Propofol, Ketamine, Midazolam, Fentanyl), their physiological profiles, and potential complications. Adherence to national guidelines, such as those from the Royal College of Emergency Medicine (RCEM) and the Academy of Medical Royal Colleges (AoMRC), is fundamental, treating procedural sedation with the same vigilance as general anaesthesia. The procedural framework is structured into five phases: Knowledge Foundation, Preparation, Execution, RSI Assistance, and Recovery.

Essential steps for every procedure involve a formal airway assessment using the LEMON mnemonic, a thorough equipment check using the SOAP-ME checklist, and a structured team brief. Capnography is mandatory for breath-by-breath ventilation analysis, as pulse oximetry has a significant lag time. Pre-oxygenation via high-flow nasal cannulae (apnoeic oxygenation) is the most critical step to prevent desaturation. Post-procedure, vigilant 1:1 monitoring must continue until the patient returns to their baseline, as a significant number of airway complications occur during recovery. Evidence for this competency is gathered through Direct Observation of Procedural Skills (DOPS), Case-Based Discussions (CbD), simulation, and a comprehensive logbook.

ACCS Learning Outcome: Provide Safe Basic Anaesthetic Care Including Sedation

The objective is to progress from a 'competent' to an 'excellent' practitioner in procedural sedation and basic airway management within the emergency department setting. This outcome requires a deep understanding of risks, pre-operative patient assessment, safe induction and maintenance of anaesthesia or sedation for ASA 1/1E and 2/2E patients, and effective management of recovery and complications [1, 2]. The entrustment decisions by the end of ACCS training include the ability to pre-operatively assess patients, provide urgent anaesthesia and perioperative care, and deliver safe procedural sedation.

Clinically Relevant Anatomy: The Pre-Sedation Airway Assessment

A formal, documented airway assessment is mandatory before every sedation procedure to anticipate and plan for potential difficulty. The assessment focuses on anatomical features that predict challenges with bag-valve-mask ventilation, supraglottic airway insertion, or laryngoscopy.

• LEMON Law Mnemonic: A structured approach to assess the airway [5]:
• L - Look Externally: Identify any external features associated with a difficult airway (e.g., small mandible, large tongue, facial trauma).
• E - Evaluate (3-3-2 Rule):
• 3 fingers: Inter-incisor distance should be at least 3 fingers wide.
• 3 fingers: The distance from the hyoid bone to the chin should be at least 3 fingers wide.
• 2 fingers: The distance from the thyroid notch to the floor of the mouth should be at least 2 fingers wide.
• M - Mallampati Score: Assess the visibility of pharyngeal structures.
• O - Obstruction: Identify any signs of airway obstruction (e.g., stridor, muffled voice, swelling).
• N - Neck Mobility: Assess the range of motion of the cervical spine.
• Dentition: A thorough check for any loose teeth, caps, or crowns is essential to prevent dislodgement and potential aspiration during airway manipulation.

Clinical Assessment: Pre-Procedural Evaluation

The pre-sedation assessment evaluates the patient's suitability for the procedure and identifies physiological risks. This is structured using the A, B, C, D, E framework.

• Airway:
• History: Ask about previous difficulties with anaesthesia, snoring, or obstructive sleep apnoea.
• Examination: Perform and document the LEMON assessment and check dentition as detailed above.
• Breathing:
• History: Inquire about respiratory conditions (e.g., asthma, COPD) and smoking history.
• Examination: Assess respiratory rate, oxygen saturation (SpO2), and auscultate for any abnormalities. Note baseline work of breathing.
• Circulation:
• History: Identify any cardiovascular comorbidities, including ischaemic heart disease, heart failure, or arrhythmias. Note any history of hypo- or hypertension.
• Examination: Measure heart rate and blood pressure. Assess peripheral perfusion. Consider the patient's fluid status, particularly in cases of sepsis where haemodynamic instability is a risk.
• Disability:
• History: Note any neurological conditions, previous stroke, or substance use.
• Examination: Assess baseline neurological status, including GCS or AVPU score.
• Exposure:
• History & Examination: Conduct a full secondary survey to ensure no other injuries or conditions are missed. Note patient weight for accurate drug dosing. Assign an ASA (American Society of Anesthesiologists) physical status classification. This LO focuses on ASA 1/1E and 2/2E patients.

Key Investigations and Monitoring

Continuous, vigilant monitoring is a cornerstone of safe sedation and is equivalent to the standard required for general anaesthesia [4].

• Mandatory Monitoring Suite:
• Capnography: Provides real-time, breath-by-breath analysis of ventilation and is the earliest indicator of apnoea or airway obstruction [6]. It is considered mandatory.
• Pulse Oximetry (SpO2): Measures oxygen saturation but has a significant lag time compared to capnography.
• Electrocardiogram (ECG): For continuous monitoring of heart rate and rhythm.
• Non-Invasive Blood Pressure (NIBP): Must be cycled every 3-5 minutes to monitor for haemodynamic changes.
• Capnography Interpretation [6]:
• Normal Square Wave: Indicates effective ventilation.
• Loss of Waveform: Signifies apnoea or complete airway obstruction.
• Damped/Shark-Fin Waveform: Suggests partial airway obstruction (e.g., snoring, laryngospasm) or a poor monitoring seal.

Treatment: A Phased Approach to Safe Sedation

Excellence is achieved through a structured, multi-phase process that prioritises safety and preparation.

Phase 1: The Knowledge Foundation

A deep understanding of pharmacology and guidelines is a prerequisite for safe practice. The practitioner must understand the physiological profile of each drug beyond simple dose recall [3].

Drug	Primary Use	Pros	Cons/Risks
Propofol	Deep Sedation / RSI	Rapid onset/offset, anti-emetic properties.	Hypotension (>15% drop common), apnoea, pain on injection.
Ketamine	Dissociative Sedation	Preserves respiratory drive/airway reflexes, haemodynamically stable.	Laryngospasm (0.3% risk), emergence phenomenon, hypersalivation.
Midazolam	Anxiolysis / Amnesia	Reversible (Flumazenil), excellent amnesia.	Respiratory depression, variable duration, accumulation in renal failure.
Fentanyl	Analgesia	Rapid onset, cardio-stable.	Chest wall rigidity (rare/high dose), respiratory depression synergism with sedatives.

Furthermore, practitioners must be familiar with the RCEM & AoMRC Safe Sedation Guidelines, which state that the depth of sedation is a continuum, and one must always be prepared to rescue a patient who enters a deeper level of sedation than intended [4].

Phase 2: Preparation and Environment (The "Setup")

This phase defines the expert practitioner. The environment must be optimized for safety before the procedure begins.

• Step 1: Equipment Check (SOAP-ME Mnemonic)
• Suction: Turned on, working, with a rigid yankauer catheter placed under the patient's pillow.
• Oxygen: High-flow source available, Bag-Valve-Mask (BVM) connected, and nasal cannulae ready for apnoeic oxygenation.
• Airway: Oropharyngeal (OPA) and Nasopharyngeal (NPA) airways of appropriate sizes, a correctly sized supraglottic airway (e.g., i-gel/LMA), and a checked laryngoscope with blades.
• Pharmacy: All sedation and analgesic drugs drawn up and clearly labelled. A flush must be available. Emergency drugs (e.g., Ephedrine/Metaraminol for hypotension, Atropine for bradycardia) must be immediately to hand.
• Monitoring: All mandatory monitoring (Capnography, ECG, SpO2, NIBP) applied and functioning.
• Equipment: A defibrillator with pads applied to the patient if they are at high risk.
• Step 2: The Team Brief
• Conduct a formal "Time Out" or use a local safety checklist (LocSSIPs).
• Assign Roles: Clearly designate the airway doctor, the proceduralist, and the monitoring nurse.
• Verbalize Plan B: Explicitly state the contingency plan. For example: "If the patient desaturates, we will stop the procedure, perform a jaw thrust, and use the BVM."

Phase 3: The Procedure (Execution)

• 1. Pre-oxygenation: This is the single most important step to increase the patient's reserve and delay desaturation.
• Apply nasal cannulae at 15L/min before starting sedation and leave them on throughout. This provides apnoeic oxygenation (also known as NODESAT - Nasal Oxygenation During Efforts at Securing a Tube) [7].
• Aim for denitrogenation, evidenced by an end-tidal O2 concentration >85% if available.
• 2. Drug Administration:
• Start low, go slow. Titrate drugs to effect.
• Be mindful that arm-to-brain circulation time can be prolonged in shocked or elderly patients.
• Flush the IV line between boluses to ensure the full dose is delivered and to avoid "dead space" stacking.
• 3. Airway Maintenance:
• Be proactive with simple manoeuvres. Snoring indicates obstruction and requires immediate intervention.
• Chin Lift / Jaw Thrust: Apply aggressively at the first sign of obstruction.
• Oropharyngeal Airway (OPA): Insert only if the patient tolerates it without gagging.
• Nasopharyngeal Airway (NPA): Often better tolerated at lighter levels of sedation.

Phase 4: Assisting in Rapid Sequence Induction (RSI)

ACCS trainees must be competent assistants during an RSI.

• Cricoid Pressure: Understand correct application (10N when awake, 30N when asleep) and when to release (during active vomiting or if it obstructs the intubator's view) [8].
• Passing Equipment: Know the ergonomics of passing the endotracheal tube and other equipment to the intubator.
• Failed Intubation Drills: Be intimately familiar with the Difficult Airway Society (DAS) guidelines [9]:
• Plan A: Laryngoscopy and intubation.
• Plan B: Insertion of a Supraglottic Airway Device (SAD).
• Plan C: Facemask ventilation.
• Plan D: CICO (Cannot Intubate, Cannot Oxygenate) - Front of Neck Access.
• Excellence Tip: Enhance team situational awareness by vocalizing time and vital signs during the procedure (e.g., "Sats are 94% and dropping, BP is 100 systolic").

Phase 5: Post-Procedure and Recovery

Safe care does not end until the patient has fully returned to their baseline physiological and cognitive state. The Fourth National Audit Project (NAP4) highlighted that a significant number of airway disasters occur in the recovery phase [10].

• Monitoring: Continue 1:1 dedicated monitoring until the patient is awake, responsive, and verbalizing.
• Discharge Criteria: Use a formal scoring system (e.g., Aldrete Score) to ensure clear criteria are met before the patient is discharged from the recovery area to a ward or home.

Complications: Recognition and Management

Anticipating and managing complications is a critical component of safe sedation.

Complication	Timeframe	Key Signs	Management
Hypotension	Immediate	>15% drop in BP (common with Propofol).	Have vasopressors (Ephedrine/Metaraminol) ready. Consider fluid bolus.
Respiratory Depression/Apnoea	Immediate	Loss of capnography waveform, decreased respiratory rate, desaturation.	Stop sedation, provide jaw thrust/chin lift, assist ventilation with BVM. Consider reversal agents (Flumazenil for Midazolam).
Airway Obstruction	Immediate	Snoring, stridor, damped capnography waveform.	Aggressive jaw thrust/chin lift. Insert OPA or NPA. Stop procedure if unresolved.
Laryngospasm (0.3% with Ketamine)	Immediate	Stridor, tracheal tug, paradoxical chest movement, desaturation.	Deepen sedation, apply positive pressure with BVM.
Emergence Phenomenon (Ketamine)	Recovery	Agitation, hallucinations.	Provide reassurance in a quiet environment. Consider small doses of Midazolam if severe.
Chest Wall Rigidity (Fentanyl)	Immediate	Inability to ventilate patient with BVM despite patent airway.	Requires neuromuscular blockade for management. Rare, associated with high doses.
Recovery Phase Complications	Delayed	Airway obstruction, desaturation, aspiration.	Maintain 1:1 monitoring until patient meets formal discharge criteria. Never leave a recovering patient unattended [10].

Evidencing Competence for Portfolio

To demonstrate progression and achievement of this learning outcome, trainees should gather a variety of evidence.

• Workplace-Based Assessments:
• Direct Observation of Procedural Skills (DOPS): Aim for at least 3-5 logged cases of procedural sedation. Also, seek assessment in BVM ventilation and insertion of an LMA/i-gel.
• Case Based Discussions (CbD): Discuss complex cases, such as the sedation of a physiologically compromised (e.g., septic) patient.
• HALO (Hobbs, Holroyd, and Langford Observation) in Sedation
• IAC (Initial Assessment of Competence)
• MCR (Multi-Consultant Report)
• MSF (Multi-Source Feedback)
• Logbook: Maintain a detailed logbook of all sedation and airway management cases.
• Simulation: Actively participate in simulation training. Attending a dedicated "Safe Sedation" course or running local scenarios on managing sedation complications like laryngospasm is highly valuable.
• CPD and Reflection:
• Utilize RCEM Learning modules, SBAs, and SAQs relevant to the LO. These automatically generate a certificate of completion in the CPD Diary.
• Reflection on all learning activities is highly valued and demonstrates a commitment to professional development.

References

1. Intercollegiate Committee for Acute Care Common Stem Training. ACCS Curriculum 2021. London: ICACCST; 2021.
2. Royal College of Emergency Medicine. RCEM Curriculum 2021. London: RCEM; 2021.
3. Brown TB, Lovato LM, Parker D. Procedural sedation in the acute care setting. Am Fam Physician. 2005;71(1):85-90.
4. Academy of Medical Royal Colleges. Safe Sedation Practice for Healthcare Procedures: Standards and Guidance. London: AoMRC; 2013.
5. Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J. 2005;22(2):99-102.
6. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency department. Br J Anaesth. 2011;106(5):632-642.
7. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175.
8. Vanner RG. Cricoid pressure. Int J Obstet Anesth. 2009;18(4):103-105.
9. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848.
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33-39.

A structured script designed for an ACCS trainee leading an RSI. This script follows the DAS (Difficult Airway Society) logic and is designed to be read out loud during the "Time Out" phase, just before drugs are pushed.

It is divided into The Situation, The Strategy (Plans A-D), and Role Assignment.

---

The "Time Out" Script

Lead (Intubator): "Okay everyone, stop for a moment. Let's confirm the plan. My name is [Name] and I am leading the airway."

1. The Situation

Lead: "We are performing a Rapid Sequence Induction on this [Age] year old patient for [Indication: e.g., reduced GCS/respiratory failure]. We anticipate a [Standard / Difficult] airway."

2. The Strategy (The DAS Approach)

This is the most critical part. You must verbalize the failure plan so the team is mentally prepared.

Lead: "Here is the airway plan:"

• "Plan A (Primary Plan): I will intubate using a Video Laryngoscope (Mac 4 blade) and a Bougie. I will use [Drug X] and [Drug Y]. We will use 30 degrees head-up positioning."
• "Plan B (Rescue Oxygenation): If I fail to intubate after a maximum of 2 attempts—or if the saturations drop below 90%—I will stop. We will insert a size [4] i-gel to re-oxygenate."
• "Plan C (Facemask): If the i-gel fails to ventilate, we will move to two-person Bag-Valve-Mask ventilation with an oral airway."
• "Plan D (Emergency): If we cannot intubate and cannot oxygenate via i-gel or facemask, this is a CICO (Can't Intubate, Can't Oxygenate) scenario. I will declare 'CICO' and perform a Front of Neck Access (FONA) using the scalpel-bougie-tube technique."

3. Role Assignment

Point to specific people. Do not shout into the void.

Lead: "Let's confirm roles:"

• "[Name], you are on Drugs. Please confirm you have [Drug doses] drawn up and flushed. Push only when I say."
• "[Name], you are my Airway Assistant. You will provide Cricoid pressure (if used) and pass me the equipment."
• "[Name], you are the Team Leader/Scribe. Please watch the monitor. Call out clearly if Sats drop below 93% or Hypotension occurs."

4. Final Check

Lead: "Does anyone have any questions or concerns before we start? ... Okay, let's pre-oxygenate."

---

Key Phrases for During the Procedure

Even with a perfect brief, communication can break down during the stress of the procedure. Use these standardized phrases to maintain control:

1. To Standardize the Handoff:

"I have a view. Grade 2. Passing the bougie... Bougie is in. Railroading the tube... Tube is in. Cuff up."

2. To Optimize a Failed First Attempt:

"Attempt one failed. Saturations are stable. I am going to optimize: Change my blade / Adjust head position / Apply external laryngeal manipulation. Going for attempt two."

3. To Declare Failure (Crucial for safety):

"Attempt two failed. I am moving to Plan B. Pass me the i-gel."

4. To Declare CICO:

"Failed oxygenation. This is a CICO situation. Open the FONA pack. I am proceeding to front of neck access."

---

Why this script works

1. Shared Mental Model: The nurse knows exactly when to hand you the i-gel without you having to scream for it.
2. Cognitive Offloading: By stating "Max 2 attempts" out loud, you prevent yourself from getting "task fixated" and trying a third or fourth time while the patient becomes hypoxic.
3. Empowerment: Explicitly telling the Scribe to "call out if sats drop" gives them permission to interrupt you, which is a vital safety barrier.

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