The first critical event I ever witnessed was in anaesthetics. It was surprisingly in the first surgery on the first day of my anaesthetics elective…
The Critical Event
A 21-year-old man had been brought into theatre for incision and drainage of a perianal abscess under general anaesthesia. I was shadowing the CT1 anaesthetic doctor who was going to be working alone. The patient was successfully induced and the operation was proceeding as anticipated.
However, the patient began to develop inspiratory stridor during the operation. They had gone into laryngospasm, likely due to the deeply stimulating nature of the procedure.
Laryngospasm is an anaesthetic emergency where prolonged closure of the vocal cords results in partial or complete obstruction of the patient’s airway. It is a protective airway reflex which acts to prevent aspiration of stomach contents. In conscious patients, this reflex can eventually be overridden by the voluntary control of higher cerebral centres. Patients under anaesthesia are not able to do this and risk severe bradycardia and hypoxia if not treated within minutes.
Management of the event
The anaesthetic doctor asked the surgeons to stop operating to prevent any further triggering stimulation to the patient. He gently suctioned the larynx clear of any secretions and performed a jaw thrust to lift the tongue off the pharyngeal wall. Unfortunately, the laryngospasm did not resolve, so he requested to get a senior into theatre. He then administered propofol to deepen the patient’s anaesthesia, which was successful in breaking the laryngospasm.
When the anaesthetic consultant came into theatre, they questioned the trainee on what had happened. The trainee responded detailing the events and steps he had taken to manage the laryngospasm. The consultant was very supportive and praised the trainee for asking for help.
Debriefing
After the surgery ended, the trainee and consultant had an informal debrief. The trainee reflected that they successfully initiated the correct steps in managing the laryngospasm, however they could have asked for help earlier. In terms of preventing the laryngospasm from occurring, they were realistic that the event was due to the highly stimulating nature of the surgery and so sufficient anaesthesia is hard to titrate. The consultant agreed with his thoughts, and added that his extubation technique at the end of the surgery was well performed.
Debriefing, as seen in this case, is a common strategy used in the clinical environment to reflect on and improve one’s practice. Walker et al (2018) outlines a debrief structure detailing the pertinent points to cover specifically between the person involved in the critical event and the facilitator:
Summarise the case
Things that went well
Opportunities to improve
Points to action and responsibilities
Debriefing can be subdivided into two types, hot and cold. Hot debriefing occurs immediately after the event, whereas cold debriefing is conducted several days later.
Benefits of debriefing
How can I learn from this?
Debriefing provides feedback for individuals, from facilitators who were actually present in the scenario. This can generate more accurate and non-biased feedback. As evidenced by Ericsson (2008), this feedback is essential for learner performance improvement.
Allows us to reflect
The process of debriefing naturally encourages reflective practice, which is pertinent in gaining awareness of one’s strengths and weaknesses. Reflecting allows individuals to focus on certain behavioural patterns, create new ideas and encourages learning (Kolbe et al, 2013). As in my example, whilst the trainee gained confidence from successfully managing the laryngospasm, the debriefing prompted him to become more aware of his limitations (lack of experience compared with seniors) and thus to remember to ask for help in the future at an earlier stage.
Improves patient outcomes
Feedback and reflection fosters learning for the future. Whilst this learning is beneficial to an individual, it also benefits colleagues. This learning culminates in improved clinical performance and patient care (Kessler et al, 2015); the principal duty of the clinician.
Drawbacks and Difficulties of debriefing
Issues with the individual
Based on the individual’s emotional state, reflection can precipitate the risk of negative emotions such as guilt and denial, which can lead to a loss of confidence in future clinical practice (Rudolph et al, 2001). However, it may also highlight individuals who are more likely to struggle with acute stress, and thus who can benefit from further support (Wessely and Deahl 2003).
Issues with the facilitator
The correlation between seniority and the ability to facilitate a debrief is commonly misconstrued. Whilst senior colleagues can use their greater breadth of clinical experience to teach individuals, this “expert opinion” can introduce bias (Kessler et al, 2015). Facilitators may lack the training or interpersonal skills to effectively carry out a debrief. In addition to this, they may lack the ability to create a learning environment where individuals feel supported and safe to be vulnerable. Innate bias and blame culture from the facilitator may also be responsible for an unsuccessful debrief (Fernandez et al, 2008).
Timing
The duration of debriefing and time at which it is conducted is crucial to its effectiveness. The increasing work in healthcare poses a burden on time for debriefing and learning (Nadir et al, 2017). In my scenario, the debrief between the trainee and consultant was time constrained as they needed to prepare for the next surgery. For some individuals, hot debriefing is not favourable as they may need to emotionally decompress after the event (Kessler et al, 2015)and have some time to reflect before engaging with a facilitator.
Figure 1 illustrates the pros and cons of debriefing
Conclusion
Debriefing can be a very effective educational technique to reflect and learn from critical events, if facilitated appropriately. Nuanced debriefing can improve one’s self-awareness, build one’s confidence and improve the quality and safety of patient care.
Whilst witnessing the critical event strengthened my knowledge on the presentation and management of anaesthetic emergencies, I will never forget the innate resolve of the team to support and teach their trainee through means of debriefing.
Author: Ankita DeshpandeReferences
1. Walker et al. “Stop 5: Stop for 5 minutes” – Our Bespoke Hot Debrief Model. https://www.edinburghemergencymedicine.com/blog/2018/11/1/stop-5-stop-for-5-minutes-our-bespoke-hot-debrief-model. Updated 1st November, 2018. Accessed 25th January, 2022.
2. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008 Nov;15(11):988-94
3. Kolbe et al. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf. 2013 Jul;22(7):541-53
4. Kessler et al. Debriefing in the emergency department after clinical events: a practical guide. Ann Emerg Med. 2015 Jun;65(6):690-8.
5. Rudolph et al. Collaborative off-line reflection: a way to develop skill in action science and action inquiry’, in P. Reason, and H. Bradbury (eds), Handbook of Action Research: Participative Inquiry and Practice. London: Sage. (2001/2006) pp. 405–12.
6. Wessely, S., & Deahl, M. Psychological debriefing is a waste of time. British Journal of Psychiatry. 2003; 183(1), 12-14.
7. Fernandez et al. Developing expert medical teams: toward an evidence-based approach. Acad Emerg Med. 2008 Nov;15(11):1025-36.
8. Nadir et al. Characteristics of Real-Time, Non-Critical Incident Debriefing Practices in the Emergency Department. West J Emerg Med. 2017 Jan;18(1):146-151.
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