There is a saying in anaesthesia (and in aviation), that the job is about hours of boredom and seconds of terror. While I wouldn’t agree that our job is boring, it is true that emergencies do not occur that often. But when they do occur, they can be super stressful and one needs to deal with them relatively quickly.
I am sure that you have had training in how to manage anaesthetic emergencies. However, the problem is, the human brain is not great at retaining knowledge and skills. Even after a training day about emergencies, unless one keeps refreshing, one quickly loses knowledge and skills, sometimes as quickly as days.
If however, one keeps refreshing how to manage emergencies, then this knowledge will be easier to access from our minds, when facing a sudden emergency and under stress. This is where the concept of BE WISE can help you.
What is BE WISE?
BE WISE stands for Brief Everyday What If Scenario Exercise.
As I will explain, it is a quick and simple method that you can use every day to mentally refresh how to manage anaesthetic emergencies. The concept is that if you mentally review one anesthesia emergency scenario every day, your mind will be better prepared when the real emergency happens. This mental rehearsal will activate your brain pathways needed to manage that emergency, strengthening them when they are needed for the real thing.
How to do BE WISE?
You can do BE WISE either by yourself or with another colleague (e.g. trainee, ODP for those in the UK).
Think of a patient on your surgical list today. Imagine one emergency scenario that could happen to this patient. (e.g. anaphylaxis after giving antibiotics). This is the “what if scenario” that you will discuss.Try to choose an emergency that you and your colleague have not reviewed recently. You can use a “menu card” that has a list of emergencies to help you to choose one. ( Click here to see a example menu card )
Once you decide what emergency scenario you will mentally rehearse, discuss with your colleague (or yourself) how one would recognise the emergency (i.e. how would it present). Then discuss the immediate management of this emergency. It is important to keep BE WISE brief and it should take only a few minutes to do. Therefore it is important to limit your discussion to only practical management and leave out theoretical/academic aspects.
You can refer to your hospital protocols and other resources to guide your discussion.
Regarding drugs needed to manage the emergency, think of where to get them (location), doses and relevant effects/side effects. Regarding equipment needed to manage the emergency, think of where they are located and discuss how they would be used.
BE WISE is not only for junior staff. Everyone, regardless of experience, needs to be prepared for emergencies!
BE WISE is NOT a test. Please make sure that you do not make BE WISE a stressful experience for yourself or for your colleague, as that would defeat the whole purpose. It’s not a pass fail type thing or an academic discussion.
BE WISE is simply an opportunity for you and your colleague to mentally rehearse emergency management. If one doesn’t know something, one just needs to look it up.
Example of a BE WISE
Imagine that you are in the operating room and that your patient is stable on the table. As it’s safe, you decide to do a BE WISE. Below is an example of the thought processes you might go through when doing it. It’s only an example so please do not use information here for actual patient care!
Let me think of a BE WISE to do. I have not done anaphylaxis for a long while, so that would be a good one to do today.
Let me imagine that my patient on the table develops anaphylaxis.
My starting point would be, “How would I recognise it?”
I suppose there would be a drop in blood pressure. And a tachycardia as well.
I may also see skin changes. I would look under the drapes to see more of the body, to get a better view.
There could be bronchospasm. Airway pressure may go up and perhaps I may hear a wheeze on auscultation.
I recently gave an antibiotic so I should be even more suspicious that it’s possibly anaphylaxis.
All this makes me make a presumptive diagnosis of anaphylaxis. Now let me think what the immediate management should be.
I would inform the surgeon and others in the operating room that I suspect the patient has anaphylaxis. I would call for help and activate the emergency buzzer. I would stop injecting anything if I was doing so, and ask the surgeons to do so as well. I would ask them to pause surgery if that was safe to do so.
I would increase the inspired oxygen to 100 percent.
I would pull up the anaphylaxis algorithm chart and use it to guide my management.
I would give epinephrine (adrenaline) early on. I suddenly can’t remember the dose. I would therefore look it up in the algorithm. Ah yes, I would give x dose.
To combat hypotension, I could speed up the fluids and lift the legs.
I would also consider giving drugs x, y, z.
My patient now has a supraglottic airway. If he had anaphylaxis, I would consider changing it to a tracheal tube as the airway could swell up making later intubation difficult.
Assuming that the anaphylaxis is well under control, I would plan further steps. I would do bloods to verify anaphylaxis and I would inform critical care as well, in case he needs to go there. I end today’s BE WISE.
If you are the only anaesthestist in the operating room, you would do BE WISE with yourself, like in the above example. However, if you are with a trainee (Resident, Registrar, ODP, etc) you could do BE WISE with each other, where each one provides some of the aspects of managing the chosen emergency. That will benefit both, “two for the price of one”.
Is BE WISE effective?
BE WISE is not a replacement for more formal emergency scenario training / simulation practice. Rather, it is there to complement such training, by keeping your mental pathways strengthened. In my department, I along with colleagues tried it out and we questioned 40 people. 90 percent of them found that it increased their confidence in managing anaesthesia emergencies. We made a poster presentation at a conference (click to download abstract).
If you study BE WISE in your hospital, please let me know and I will put your results on this site.
Please help me spread the word!
BE WISE takes only a few minutes every day, but could someday help save your patients life (and perhaps yours as well!). I would be grateful if you will please spread the word about BE WISE to your colleagues near and far. Thank you!
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