Simulation training for high risk, low incidence scenarios is now common in emergency medicine. Whether it is training for a ‘can’t intubate, can’t oxygenate’ scenario or team-based crisis resource management, stepping in to the sim lab should mean that when a real-life crisis occurs you have already rehearsed the steps you need to take to make it through with dignity intact.
Last week I took part in the ultimate simulation training for those involved in retrieval medicine, the dreaded HUET training. Minh has already written about his experience in Helicopter Underwater Escape Training here and I took a lot of his experience onboard before I went in the pool. I’d even taken to Twitter to poll others for their HUET experiences and I felt the universal shudder from all those that replied.
The morning of theory began with inspiring images of helicopters flying at speed and performing acrobatics to a high-octane, Queen-based soundtrack followed by a talk through of the risks of ditching at in the water and how having processes and procedures in place can make your chance of survival much better. This was followed by the practical portion of the training.
I was repeatedly dunked, upside down, in the simulator, to make my escape to the surface. Whilst the initial escape scenarios seemed straightforward it was only when I was trapped upside down waiting for my buddy to leave so I could utilise my secondary exit did a little bit of fear creep in. HUET training is very safe. There were two rescue divers in the pool as well as two spotters at all times. This knowledge goes out the window as you take a deep breath and wait. There may be four of you trapped in an oversized lobster pot but once you are under it is really just you. Sounds are muffled and directionless. If you are as blind without your glasses as I am your sight is no help either. It was easier to keep my eyes shut through every iteration of training and rely on my sense of touch and the lessons I had learnt. I had established my reference point and, once I found that my primary exit was blocked, reached over to establish a new one in the seat next to me. There was still someone sitting in it so I waited. Chivalry is not dead, even underwater. By the time she had exited the vehicle my breath was beginning to run out. As my focus began to narrow my harness began to tangle and I could not get myself free. The safety diver tried to pull me out but I was too strong and kept on resisting. Fortunately the instructor nearest me had seen what was going on and signalled for the cage to be raised and I caught a breath.
The skills learnt in HUET training are transferable to real life. Not just for wannabe James Bonds but for those about to intubate the critically ill patient. Like the novice intubator I had fallen into the trap of thinking it was going to be easy. I had not taken proper notice of my surroundings and when things got hard I began to lose awareness of everything around me. I ignored the assistant that was trying to help me and only when outside forces intervened was I safe.
So next time you are going to intubate take a deep breath, establish your reference point and utilise bridging manoeuvres to establish your goal. Use the bougie as an extension of your arm. Lack of hold-up establishes a path and only once the tube has been delivered is it safe to let go. Don’t ignore those trying to help you (and certainly don’t kick them in the head) and have a back up plan. Two hands on my head indicated I was struggling and I was winched to safety before personal desaturation could occur. I don’t recommend this as your sign to the team that you are in a ‘Can’t Intubate, Can’t Oxygenate’ scenario but you need to have briefed the team on what you will say/do in such a scenario before it even occurs.