Prepare, delegate and prioritise

Residencies impose many challenges on participants: long work hours, weird and wonderful cases, research demands, financial worries and a constant feeling of needing to prove your worth.

I’ve talked about imposter syndrome many, many times over the years, so I’m not going to focus on that. It’s there, we know it is, and I’ve given it more than enough attention. Back in your box, imposter syndrome.

Instead, what I wanted to focus on was some of the paraclinical skills I’ve developed over the past three to four years of internship and residency, in the hope that I can provide some quick tips for improving efficiency and reducing the stress in some of our more emergent cases.

While I’ve put many things on hold while pursuing my ECC endeavours, I would like to think I’ve managed to become quite efficient with my day-to-day work and have managed to continue plodding along with additional academic challenges, such as publishing and presenting, where I can.

I’ve truly thrust myself into the residency life, and while I’m looking forward to a change of pace in six months’ time, I can safely say the residency has taught me many skills I will hold on to as I progress through my career. So, let’s get cracking.

Fail to prepare, prepare to fail

Yes, I went there. I know it’s cliché, but learning to prepare has been a huge source of stress relief for me throughout the residency. Whether it is learning to cook so I could invest in some tasty meal prep recipes, or having mental checklists for what I might need with the next emergency case, preparation gets the ball rolling, so you can hit the ground running. Let’s take an example.

A client rings in and says that their two-year-old, male, neutered domestic shorthair has been straining in the litter tray for the past three days. They think he’s a bit constipated and he’s been getting progressively lethargic, and now he’s really not wanting to move or do anything at all.

We all know where this is heading: this cat could be a few hours away from a hyperkalaemia-induced arrest due to his urethral obstruction, or he could simply need a micralax enema.

Here’s where preparation starts. You probably haven’t taken the phone call, unless it’s out-of-hours and you take phone calls directly from the client. More likely, your lovely reception team has taken the phone call.

Now, we have some fantastic veterinary receptionists in the profession and I am a firm believer that rapid phone triage and identification of possible emergencies is the first step in any smooth emergency case. Invest the time in training your receptionists in what constitutes an emergency.

For many, veterinary receptionists won’t receive formal medical training, so you can’t just expect them to know what needs flagging. All it takes is an hour or two of your time to draft a list of emergency presentations you want highlighting to the staff on clinic when they take an initial phone call – couple that with some in-clinic training and you’ve instantly streamlined your emergency service.

For all of the flack NHS 111 gets, the staff are well versed in distinguishing emergency from urgency or the more routine medical problems.

Moving along, let’s assume your well-trained reception team has highlighted this as one of the possible emergencies, and you’ve got 10 to 15 minutes to get things ready. I want you to practise visualising the upcoming emergency. Think worst case scenario. Plan your first five minutes.

This is now routine for me whenever I hear something sick is coming in, either as a referral or through our first opinion service. RTA? Well, let’s keep it simple with some airway, breathing and circulation preparation. We’re going to need to be able to potentially secure an airway, so I’ll probably need an endotracheal tube or three, a tube tie and cuff-puff, a urinary catheter for if things aren’t going well and, worst-case scenario, a large-bore IV catheter and scalpel blade.

Next up, we’re probably going to want to establish IV access so we can provide some analgesia and fluid therapy. Throw in an ECG and an ultrasound probe, and we’re golden for the first five minutes.

How many cricothyrotomies or emergency tracheostomies have I needed to do? Honestly, not many – most airways you can secure with a urinary catheter. But the handful of times I’ve needed it, I can tell you that the situation is so much more unnecessarily stressful when you’re running around trying to find equipment. I would much rather have this prepared and not need it, than need it and not have it.

Having everything prepared also acts as a prompt for you to perform certain tasks or consider certain management strategies when that case arrives, and actually really is sick. We all get tunnel-visioned during emergencies, but your pre-prepared visual checklist will help you work through all the essentials of stabilisation.

Back to our possible blocked cat: what’s the worst-case scenario? I have seen many blocked cats since transitioning to emergency and critical care work, and we all know they present on a spectrum of severity.

I’ve had the blocked cat with a potassium of 10mmol/L (reference interval: 3.6mmol/L to 4.6mmol/L) that has all manner of arrhythmias, ranging from ventricular tachycardia (please don’t give the lidocaine) to severe sinus bradycardia and sinus arrest. The bladder isn’t going to kill the cat, the potassium will. What’s our drug of choice? Calcium. Calcium is your friend here – have it nearby before the cat even arrives and then when the cat presents comatose with a heart rate of 90 beats per minute. Rather than panicking, you’ll automatically think back to your pre-prepared list and grab the IV access and administer calcium.

Want to be even more streamlined? Have a list of doses in mg/kg and ml/kg in your “emergency bay” – anything you can do to reduce the thinking needed the better. You don’t necessarily need the urinary catheters ready for the first five minutes, but once the patient is more stable, you can spend the time getting ready for the next big step (urethral catheterisation).

Now, maybe the cat truly is constipated and just needs some fluids and a micralax, but for the five to 10 minutes of preparation, I can almost guarantee you will feel less stressed with everything ready. Of course, we don’t always get 10 to 15 minutes notice. Sometimes, we get no notice and patients are rushed in off the street. So, make sure you have your emergency area well stocked and organised. A tidy house (or practice) makes a tidy mind.

Delegate where you can and prioritise where you can’t

We can’t do everything ourselves. In fact, certain tasks we can do, but probably shouldn’t.

Look, we all want to be helpful. No one likes the vet that sees the faeces in the corridor and walks idly by, pretending like they didn’t see it. Take the 30 seconds to pick up and bin that poo when you can.

But would you spend the time picking it up while there’s a dog that is having a BOAS crisis that needs intubating? Probably not, but that’s a shit example… yes, I went there.

If you stick with me, we’ll walk through a more relevant situation where delegation is key. Cardiopulmonary resuscitation is the epitome of life and death situations; this is not the time to be a hero, and it is not the time to try to do everything yourself.

I am incredibly fortunate to work among a team of amazing and inspiring emergency and critical care nurses. While we all have crashes that are more chaotic (the dead-on-arrival, the staff pet), the sign of a good crash is silence and machine-like efficiency.

A well-led crash requires a designated leader to oversee the task, to take that helicopter view and observe it all. Can I do all of the roles needed during a crash? Well, you’d hope so, given I’m almost finished with the residency. Do I do all of the roles during a crash? Generally, no, that probably wouldn’t be an efficient use of my time. Why should I spend the time intubating the patient when three other people are present that are more than capable of doing that procedure? What happens if I’m trying to intubate the patient when plenty of capable people are around me and other tasks need completing, such as obtaining vascular access, or more extreme, surgical procedures such as opening the chest?

Doing procedures that other people can do not only prevents other team members from gaining much needed practice, but also detracts and distracts from other tasks that need you.

The leader should ideally be away from all of the other roles, but I appreciate you may not have enough people for this to be the case. If you’re leading and you have to get involved, I’d recommend being the scribe and/or be in charge of drug administration.

Learn the skills and strengths of your team members and invest in them. We have a pool of incredibly skilled and enthusiastic members of the profession, ranging everywhere from veterinary receptionists, patient care assistants, veterinary and veterinary nursing students, RVNs and veterinarians. Use them (author’s emphasis).We regularly get our students involved in crashes because they are more than capable of doing so and they often love being included. They can easily take on the role of scribe and call out every two minutes to keep things organised.

Sometimes, situations will occur where you can’t delegate. As the leader during an arrest, I will keep an eye on the most important tasks: how long have we attempted an airway? How many attempts at an airway have been made? Have we established IV access yet? These tasks are delegated, but sometimes more complex procedures may specifically require your training. Maybe someone needs to do a cut-down or place an intra-osseous catheter, and no one else is confident to do that but you; well, you’ll need to take a step away from leading and get involved, but until then, you should probably stay in your lane.

As a side note, if you do have to take a step aside from leading, I’d definitely recommend you ask someone else to take over – I have only ever regretted trying to lead a crash at the same time as doing vascular access cut-downs or surgical airways; we get too task focused and forget the basics still need to be done.

Please note that none of the previously mentioned is based on me being the veterinarian. It is very common practice in human medicine for crashes to be nurse-led and this is something I am very keen to see in veterinary medicine – we should be training those around us in the attempt to up-skill the whole team.

We have veterinary nurses happy doing cut-downs for vascular access and dealing with difficult airways, so I use them. Allowing your staff to progress serves multiple purposes: it provides career satisfaction, but also allows you to focus on the tasks that only you (at this time) can do.

Finally, the delegation doesn’t have to only take place during high-risk situations. You probably know in your head what you want doing with the three inpatients that you’ve just worked on admitting, but you’ve got another two consults waiting. Do you really need to be the person to place their IVs and grab bloods?

Spend a few minutes writing things down on the hospital sheet and allow other people to get involved. Your hospital sheet is your prescription – take the time to work on it and keep it clear. Do you need to personally assess the dog in congestive heart failure every hour to assess whether it needs furosemide? Probably not, so why not put a furosemide plan on the hospital sheet? For example, “If respiratory rate > 40, please give 1mg/kg furosemide intravenously. If respiratory rate < 40, please reduce O₂ by X%”.

Suddenly, you’ve not only ensured your patient gets the care they need, but you’ve also freed up some mental space for you to focus on your other patients and consults.

Mastery of delegation and preparation requires practice. Don’t just reserve it for when you have a billion things to do, because then the only time you’re doing practising is when high stakes and high stress are present.

Nothing is stopping you spending the time to practise the aforementioned, such as investing in the hospital sheet, and then working through the checklist of requests yourself. Share the workload and don’t use delegation as an excuse to get lazy.

That’s all, folks

If you have a question or want to discuss a topic from my ECC Endeavours, please feel free to drop me an email at [email protected] and I will try get back to you as soon as possible. Until next time, take care.

As always, the views expressed in this article are mine alone, and do not necessarily represent the views of my employment or affiliated institutions.