Transcript for Introduction to the CCrISP and START materials video
[Steve] I'm Steve Cavanagh, I'm a vascular surgeon in York. I've been a consultant for about 16 years. I've been involved with CCrISP since I was a registrar, when it started, and I'm currently programme lead for CCrISP and the START. The CcrISP course is a course aimed at core trainees in surgery. They all have to do it essentially. It's a well respected course, it's international now. The START course has been around a bit less time, that's aimed at foundation year doctors, we've just finished rewriting it and that's gonna be applicable to foundation year doctors of all specialties with a completely updated manual that we're looking forward to trying to roll out nationally.
[David] My name's Dave Yates, I'm a consultant in anaesthesia and intensive care medicine at York. I'm one of Steve's colleagues from there. I've been involved in CCrISP for many years now as an instructor, and I've also been involved in the latest rewrite of the START course.
[Ben] My name is Ben Lindsey, I'm a vascular and transplant surgeon based at the Royal London Hospital in Whitechapel. Like David and Steve, I've been involved with CCrISP for a long time, and START from its inception, and I think these are, although, surgically badged courses, have an immense amount of relevant medical knowledge and principles within them, and I think in this current climate with COVID-19, there are some resources here that are particularly useful for all of us.
[Steve] As I'm recording this now, we have some cases in our area, but not a huge number of cases, certainly not as many as in London. So, we're in a different part of the curve. We're still in the kind of preparatory phase, really. We've still got plenty of capacity, but we are getting cases through. We're still on-call for vascular surgery, we'll cancel elective surgeries, everywhere else has. But we're still getting some acutes through. We've, on the advice of a Chinese registrar, actually, we've split into three teams of surgeons with juniors attached, and we're keeping those teams completely separate, and that was the experience from China that everyone was getting infected at the same time and there was no resource of doctors. So, we're doing one week of full-on on-call seven days in a row, but buddied up with each other, if one of us gets ill, and also to help with the decision making and operating. Another week where we're doing admin which is what I'm in this week which is office-based and dealing with telephoning patients, doing telephone consultations, looking through all the results. So, that's an interesting experience. And then, the third week, have some time off, stroke covering for colleagues when they get ill.
[David] Yeah, and in Intensive Care in York is, as Steve says, not as busy as some others around the country, certainly nowhere near London, we still have plenty of capacity with being training and pulling in colleagues from theatres, both the nursing staff, ODPs, healthcare, et cetera, and our anaesthesia colleagues to come and get up-skilled on ICU. It's been a fantastic response. I think we are all still sort of awaiting that tsunami of patients that they saw in London and hopefully we won't see it, obviously, but I feel that we're ready. We've had a few sort of eye-opening moments that have really sort of hit home and I think things like not being able to get loved ones in when patients are dying on your intensive care unit is particularly hard, and that's really hit the staff very badly. Having to just phone up and say your loved ones gonna pass away is pretty grim. But, it's early days, I know that things are worse elsewhere in the country, elsewhere around the world. For us, for us in intensive care, this is in terms of the medical side of it, this is what we do. This is A to E medicine. We're looking at each patient. We're doing the ABC for each patient and that's what we do everyday, every time we see a patient. And, that's why I've got involved in this, in the CCrISP and the START side of things, 'cause I can see a huge benefit of using the skills and the knowledge that you gain from the CCrISP course and the START course. And it can translate very rapidly into caring for these very sick patients.
[Ben] So, I'm in London and we are in the middle of the eye of the storm, I guess. I was just saying to my colleagues earlier on, I just finished a seven day stretch working in ITU as a lines doctor. So, we pick up a list of people who need either arterial lines, vas caths or central lines and work our way through it. But, I think there are some, lots of issues here about what's happening to other surgeons across the country. And, I think in a way, it's easier for us in London, because it's clear why we aren't doing our routine daily stuff, whereas as I suspect there's a lot of waiting around in some of the less affected areas, waiting for something to happen. And, I think, for surgeons that can be pretty stressful, 'cause we're not used to not doing what we normally do. And so, that impact, I think, is a sort of a more vicarious injury, if you'd like, to ourselves and our colleagues.
[Steve] So, in terms of the CCrISP algorithm and during the COVID pandemic, this couldn't be better designed, I don't think. The algorithm is all about a structured approach to every patient, even when you're out of your comfort zone, in the middle of the night, more junior, with a condition you're not familiar with it, it couldn't be better designed for this. And, it talks about A to E assessments, of course; it's absolutely essential to maintain life. These are things that are gonna kill a patient first. We're all taught that at very junior levels now, be those paramedics, nurses, med students, doctors. What we find teaching this course is that people often struggle to move beyond that, and the beauty of the algorithm, is it will actually give you skills to move beyond that and reach a diagnosis and institute definitive management. And that's the beauty of the algorithm. And, I'd really endorse it at all times to treat sick patients, particularly in these times when we're all out of our comfort zone.
[David] I think, Steve, I'd add to that, the A to E part of it that we're gonna talk about in a minute, whilst it is fairly, it's designed to be basic stuff that you can teach to the junior members of staff, but we have seen historically that it's just not done well. And, when you start teaching it routinely and regularly, you see outcome benefits. So again, it sounds fairly straightforward, an A to E assessment, but in fact doing it well is absolutely crucial and that's really what the START and the CCrISP is all about.
[Steve] And just to, I agree completely Dave, and the thing about these courses are, it's about application of knowledge. If people are looking at these materials thinking, I know all that, that's fine, we expect you to know it, it's about how you apply that knowledge in the real world to get the results that you want from the outcome for your patients.
[Ben] Underlining what David is saying about the fact that it's applying a system that often we don't apply well, you only have to spend an hour in full PPE before you realise that your brain is not thinking as quickly as it would have done. And in fact, when you've done two or three hours, which a lot of our intensive care colleagues are on their ward rounds--even though the ward rounds are split up into different teams--to have something that you can hang a structure onto, particularly, say, if you're working in A and E where some comes through unwell, you're gonna be in PPE when you're assessing them, it's so easy to make an unforced error, and I think the value of this particular algorithm, in the current climate, is very valuable.
[Steve] Well, as programme lead, I'm very thankful to the college for releasing all this material both from START and CCrISP, which is a really altruistic thing to do, I think, in these circumstances. We're very conscious people might be overwhelmed by the material, so I would say there's three elements to looking at it. I think everybody, no matter who they are, nurse, a doctor, healthcare professional, allied healthcare professional, could benefit from looking at the CCrISP algorithm section and thinking about how they're gonna use that algorithm in their day-to-day practise. And the Human Factors things, we're all super motivated to look at that. So, I think I'd really recommend looking at that. I think the START and CCrISP materials are there to be dipped in and out of, depending on your specialty and I'm going to let my colleagues, Dave and Ben speak about them in more detail.
[David] Yeah, I think the CCrISP manual has a huge amount of information in there. It is vast. And, I wouldn't really, well I don't think anyone should be expected to read the whole thing at the moment, but I think the crucial parts are probably the Respiratory Compromise in the Surgical Patient. I think if you read that chapter along with the chapter along Hypoxia in the START course, I think that gives you a very nice background into what's going on with a lot of these COVID patients and I think there's a lot of information in there that will help on the general wards, as well. I think the Cardiovascular Disorders, Diagnosis, and Management chapter in the CCrISP book is also something else that, it would be very useful for whatever you're being asked to do within the hospital, and also it will stand you in very good stead moving forwards as well. It's good revision. And then, the last two I'd suggest would be the Renal Failure Prevention and Management chapter and the Fluid and Electrolyte Management chapter. What I've kind of described is almost like ABCDE, isn't it? It's remarkable how it all comes back to that: get these bits right and we're doing an awful lot of good for an awful lot of patients.
[Ben] Just to follow on from that, I think, once you put it into the context of environments that you're going to be exposed to during the pandemic, it underlines the need to have an absolute lifeline to go back to, so that you don't make any unforced errors. In terms of the difference between CCrISP and START, the CCrISP course is obviously a very established course. It's in in fourth edition and it tends to be learned by, or the group of people using it are the, are those junior registrars wanting to further their surgical career; whereas the START course is delivered to the FY1 doctors. We've also suggested it might be part of the medical students final year curriculum in the future. That's the level that it's at. It's very up-to-date, so I would suggest that, in the context of what I'm about to describe, the START resource would probably be the first one to go to for anyone who is less familiar with current, post-graduate medicine, so these are nurses, these are allied healthcare workers, advanced physicians, physios, who may well end up in a situation that they're not comfortable with. So, just to tell you what's happening at my hospital: our ITU beds are usually in bays of four, currently we have between five and six in a bay of four. So, the bed numbers go two, 2.5, three. And, we don't have enough intensive care nurses because they're exhausted or in isolation. So, in a bay, I was working in a bay last week and we had one ITU nurse and five volunteers, of which I was one. We had a year eight max-fax trainee who can't sit their FRCS, 'cause that's not gonna happen. She was acting as a nurse. And we had a medical student as part of the group of people caring for these individuals--oh, and a dietician. So, the value of having something upon which to structure, combined with an understanding of the emotionally intelligently demanding aspects of conducting ourselves in these quite dystopian times, I think to summarise would be, the START algorithm and the Human Factors section because I think that would go along way to keeping everybody optimally managing the patients.