STARES 2 - Risk Management

SITUATION
Mr B is a 57 year old male who is day 1 post elective right thoracotomy for an right upper lobectomy to remove a malignant mass. The history of presenting complaint was a few weeks of haemoptysis episodes with the occasional wheeze and cough during the night. He has a past medical history of a previous alcoholic cardiomyopathy, ex smoker quitting 7 years ago with a 80 pack/year history. He is also an ex heavy drinker having 10-12 cans of beer a day, but has not had a drink since 2003. He also has hypercholestoraemia, gout and hyperlipidaemia. Mr B lives with his wife in Perth and is currently not working. Mr B had an uncomplicated operation and ICU stay and returning to the monitored ward the night of his operation.

TASK
To complete a chest review and if the patient is suitable, ambulate.

ACTION
After introducing myself to Mr B I then explained the plan of the treatment session today, in which i was hoping to have a listen to his chest, teach him some deep breathing exercises to maintain healthy lungs, and if he was feeling up to it and his obs were stable to go for his first walk since the operation ending the session by sitting out in a high back chair. After getting Mr B's consent I began a quick subjective assessment. After this I then began a respiratory assessment, starting with his oxygen saturation then teaching him a supported cough. I then listened to his cough and his chest. After this I organised my environment, by getting a trolley for him to ambulate with which contained an oxygen bottle and a IV pole, which I attached his PCA to and also organised all his attachments in preparation to get him sitting on the edge of the bed. Once I had my environment organised I got Mr B to begin to walk his legs towards the edge of the bed and then come up into sitting. Once sitting on the edge of the bed I then attached his two ICC's which were on 5 kPa of suction, his nasal prongs and his IDC to the trolley for him to stand and ambulate. After ambulation, I then reassessed Mr B's cough and auscultation.

RESULT
Mr B was resting in bed, alert and orientated when I came to see him. Mr B was in 2/10 pain at rest. He had not been coughing/productive of any sputum since the operation, and was not normally productive of sputum prior to the operation. Mr B states that he wasn't that active prior to the lobectomy, walking one kilometer a day and did not require the use of any aids or services. I then taught him a supported cough, which was strong, dry and non-productive and didn't increase his pain. On auscultation he had decreased breath sounds bibasally, a fine end inspiratory wheeze and a gurgling/air leak sound in the R UL. Mr B only required 1 min assist into sitting. Once sitting Mr B felt a little light-headed which soon settled. Once the environment was set up and all of Mr B's attachments were on the trolley I instructed Mr B to come up into standing. As Mr B did this he pushed through his arms on the bed. What I didn't see was that underneath his gown, Mr B pushed through one of his ICC's as he went to stand up. This then caused Mr B to disconnect one of his ICC's from the most proximal connection. This was quite obvious because as soon as it happened you could hear the hiss of the suction. Once I managed to find where along the line of connection from his body to the wall where he had disconnected it I quickly reattached it. I immediately got him to lie down, watched his saturation while my supervisor told the nursing staff who informed the medical team. It was then decided, considering Mr B's oxygen saturation was maintained at 98% that Mr B was safe to continue to with physio, and ambulate. It was then onto take 2 in attempting to stand, where I made sure I could see his ICC tubes and that he didn't use his arms to stand. Once in standing Mr B ambulate with the trolley for support and the attachments and 1 stand-by assist. Mr B's O2 increased to 100% during ambulation and after ~10 m he was returned to the HBC and encouraged him to sit out of bed for at least and hour. On reassessment, Mr B's cough and auscultation did not change.

EVALUATION
I found that after treating this patient and after having his ICC be disconnected that I was really frustrated. The reasons for this was because the previous day I had told my supervisor that one thing I wanted to improve on was setting up my environment and becoming confident in the handling of attachments, so I had made extra effort in setting up my environment and making sure the 2 ICC drains were in the correct positions for when he sat up and then placing them on the trolley so that when he stood and ambulated he would stand on or trip over the tubing. So when he went to stand and leant on the tube, forcing it to disconnect I felt frustrated and annoyed that after making the conscious effort to be prepared and even more aware of the attachments, I was that unlucky to have my patient lean on the tube. As soon as the tube was disconnected I did become very flustered, however I think being like a duck on the water I remained cool on the outside but under the water I was frantically paddling my legs.

STRATEGIES
One good thing that comes out of this horrible experience is that I will never let something like this happen again. When seeing this patient next and any other patient I will make sure to check all connections of the attachments were disconnection to occur and make sure that all are visible to me and safe. When treating a patient I think it would be a good idea to just take a couple of seconds to familiarise with the environment and what attachments the patient has.