 My name is Bill Pelage, I'm a nurse anesthetist at the Pittsburgh VA, and as a staff anesthetist there, our patient population are veterans. Nationally, veterans are subject to about 20% PTSD. Of that same percent, about 20% of those patients are also subject to emergence to laryngeum and that would be a bad wake up or a violent, potentially violent wake up post-operative following an anesthetic. And also nationally, in the civilian population, it's about 5%. So the likelihood of emergence to laryngeum is much higher, it's five times higher in a veteran population. The easy definition is an abrupt awakening from an anesthetic, it could be any anesthetic or for any procedure. What the anesthesia does is, there's a period as the medicine from the period of you being absolutely asleep and sedate to waking up, I call it a bridge, it's called stage two anesthesia. In that stage, when your ears and your senses are emerging from that anesthetic, it is a period of confusion. It's a period where if there's involuntary movement, action, crying, really any behavior that would be involuntary, that short bridge, stage two anesthesia, waking up is also the most dangerous period. That's the period where under the wrong circumstances, you are easily triggered by a sound or it could be a voice. What we found in what's proven is that a female voice upon emergence is better safer than a male voice. And the theory, at least on the military side, is that a female voice would potentially remove you from a combat experience because it's a female voice that would be potentially more calming, more soothing, and also not remotely attached to your combat experience. If that's the source of your PTSD. So our concentration as an anesthesia provider is emergence to laryngeum. Emergency to laryngeum is usually, there's usually a triggering event and so triggering event could be a loud noise, a smell, a sound, it's usually an abrupt noise. And you're reading in reading of PTSD. It's it's those people combat veterans in particular that would avoid July 4 celebrations if they used to hunt they don't hunt anymore. It's that loud abrupt noise, which acts as a trigger event under anesthesia or emerging from anesthesia. The drugs that we use they they suppress, they suppress you in a manner that you can't distinguish. It's a combat experience. You can't you're unable to distinguish what that noise source is. And so it may trigger a flashback or an episode of violence. Project on Eagle was actually started in 2012 so it's it's 10 or 11 years old. Initially it was to pack you nurses at the Pittsburgh VA that they clearly identified that the patients waking up that were most likely to be violent or confused. Also had a history PTSD. So it was brilliant for these two to to say how you know how do we screen and identify. So early on in that 2012, they would pre screen each patients. Each patient on the schedule for a history of PTSD traumatic brain injuries is related sexual assault violence, things like that, or a history of emergency delay. And so those patients were screened like today for tomorrow's schedule. It's just brilliant for them to say, we're going to give these people a quiet room in the pre up area, and we're going to give them a yellow or cap so that everyone on in the perioperative area knows that this patient, if nothing else is is more likely to wake up poorly bad or with violence. I just started there six years ago. I'm a veteran myself. And I noticed for myself that my, my, my event was being in the recovery room, and seeing an old gentleman screaming get down get down. He was clearly not in Pittsburgh he was, he was in Vietnam. And, and it's screaming and swearing that I was going to be shot. And so when I approached him, I thought, you know, I'll, I'll do a little hands on I'll call him I'll talk him out. And that was that was definitely the wrong answer it's just ineffective. So once I got within arms reach he threw me to the floor. And, and when I got up, I knew right then that, you know, we have to do better. You know, it wasn't enough that we know who and identify or pre screen, who was going to have these episodes of violence. It was my mission that day, getting off the floor that, you know, there's got to be a way to prevent this. And that's where project only ago kind of became reborn. And it was a matter of me speaking to the right to individual at Pittsburgh VA and behavioral health. And then it took us about 14 months to formulate. What's now known as Project Golden Eagle, taking it a further step to not only pre screen and put patients in a quiet area, but do a better preoperative assessment. Or, you know, what are their triggers what what is their history of PTSD. And what we found and what we know is that PTSD of any form, whether it's a childhood event sexual assault. It doesn't have to be combat and it just has to be a an event in a person's life. At the VA, of course, we see more combat and more those type, you know, military related stressors. Because that's the environment we're in. But so what we do is we assess better. And then we plan better. And, and what we found myself in a man the backstab my anesthesia partner is that there's really just two drugs that make that situation worse. The PTSD brain is now physically and chemically different by MRI by scans. Someone with PTSD their brain now functions differently. When when triggered or or with an episode of anesthesia related emergency area. And so, so just a matter of good reading and research. You know, there's, there's two agents that make that situation worse. So we are anesthesia management is to eliminate these two agents and go with the drugs that are proven are expected to perform better. And since 2018, our, our injury rate has been zero. We implemented somewhere we implemented the anesthesia portion and the hands on training for all the perioperative staff in 2018. Since then our injuries are zero. And we really attribute that to a solid prevention strategy of doing a better assessment planning better planning the medications better, and then following through with it with a safer and smarter plan. When we look at the statistics and and how these how they impact patient behavior upon emergence from an anesthetic on a civilian side, it's about 5%. I practice, I have 20 plus 25 years practice in a civilian facility, and now these past six years at the VA. And what I think the success of our program translating to another civilian agency or hospital. It's just a simple matter of asking a couple more questions on preoperative anesthesia assessment. If in any hospital, a patient is asked if there's a history of violence in the home or domestic violence. It's a simple yes no question but that doesn't translate to an anesthesia plan. So what we do once the patient is pre screened for PTSD, and we, we know that patient is subject to or maybe subject to emergency to wear. And so what we've done is the, the patients, the 15 or 20% of patients that we see that are not, or they're either not pre screened for PTSD or sexual assault. So that puts us kind of in the same category as the civilian population, whereas these are patients who either don't have a history or a known history of emergency alarm but may have a history of PTSD. And so taken project going to go out of the Pittsburgh VA and and trying to adopt it outside. It's, it's honestly just, it's just an assessment. You know, is there any history of PTSD of any cause or sleep disturbances. I think the younger generation younger meaning, not Vietnam veterans, more Iraq, Afghanistan, you know the last 20 or 25 years. I think that stigma of PTSD is gone, whereas it existed or it seems to exist stronger with the older veterans. And so, so a question of PTSD or sleep disturbances seems to carry a conversation for a patient to, to either admit or think that, you know, the last time I had surgery. You know, I was held down and, and that bothered me. And we have an incident. Amanda took care of a patient. She was a college age. And she, she was putting off her surgery because she she awoke in a period of emergency. At a civilian hospital. And, and as her behavior manifested into, you know, fear and violence. She was, she was locked in a state where she was reliving her sexual assault. And, and without the training to identify, assess and plan for a patient like that. So our staff did what they thought was best they held her down, which only escalated her confusion and her state of violence. So this program going outside of our facility is really it's on that cost, but we're on first base. So we got up with the Pennsylvania safety authority. In 2021. And that organization assigned us a writer Matt Taylor research analyst. And so we looked at first the Pennsylvania civilians statistics of emergency solarium, going back through. I think we started at 2000 incident reports. And then had to identify from that, which of these were anesthesia related across the civilian Pennsylvania population, got that down actually to 97 ever clear cut anesthesia related. That information that study was published in December of 21. And then what we did was from that program or that study. We looked at just project going to to kind of plan for under under the Pennsylvania safety authorities direction was to make our program, almost a how to manual. So what we published in December of 22. It's a, a, a, it's a how to manual it's like the manual that came with your TV that nobody rates. It's start to finish how to identify how to assess how to plan. And, and so there's the anesthesia side that's 50% of it and then the other 50% is how to train your staff. And that's, that's as important as the anesthesia and it really is 50%. So the planning side for the non anesthesia. We look at those assessment questions and the planning to train the staff to better react individually and as a team to safely restrain a patient. And, you know, at the same time protect themselves from injury. In the emergency scenario episode. We define it and we wrote that there's, there's a there's a clear line between violence and non violence or dangerous versus non dangerous. So non dangerous and non violence. What we define would be the patient is not a harm to themselves or harm to the staff. That could include insoluble crying, crying to the point of being hysterical crying. When a patient is in that state, they make eye contact, you know, but clearly they, they go to sleep in Pittsburgh, but clearly they wake up in Iraq, or, or at the time or place, or emotion of their, their episode or event that, you know, brings about this PTSD and emergency to learn on the, on the non violent side, we've had patients that are inconsolably crying, they'll pull the covers over their head. It's, even though it's not violent, it's still a period of awakening in that stage two anesthesia where, you know, we, we speak we say it's going to be okay, you know, maybe touch a patient put your hand on your arm. But they're still in that zone of stage two, where that doesn't always work. And so what we do is we have a medication called precedent. So precedent is, I like to call it a soft set it up. It's a soft set of because this drug puts you in a, it really does sedate you to a place of tranquility. It's a calming drug, but it takes five or 10 minutes to work. So in the, in the, in the episode of non violence. This is a drug that works great. It works great because it, it doesn't set up so fast, but it's dates the patient to the point where they're still able to, to answer you, or they will be shortly. It's, it's, I think the analogy is, you know, everybody wants to smooth landing in the airplane. But for, for someone like this of emerging from anesthesia, we want that runway to be a little bit longer. So we would use a drug like Presidix as a preventative strategy towards the end of the procedure, you know, or surgery to lengthen that runway and land this plane a little more smoother. So in the opposite spectrum, I, where there's an episode of violence of self harm or patient harm. I mean it's thrashing it's kicking it. It's pulling out IVs it's pulling up breathing tubes. It really is a, it looks violent, and it is violent. And it's potentially dangerous to the patient or to the staff if they're not trained to, to approach a patient correctly. So verbal de-escalation. I'm going to honestly say that that's out of the ballpark. It doesn't work. So in a period of violence, where that preventive strategy is now useless, essentially. So we would use a stronger drug like Propofol, which, which onsets very fast. So we like to teach that Presidix prevents a fight and pro-Propofol stops a fight. Despite our, despite our best assessments for PTSD and related behaviors. This is the potential for emergency learning. Absolutely. So what we've done is we've expanded our assessment question. In 2012 project, only looked for screened or asked about a history of PTSD in trauma or combat experience. And, and that really doesn't begin to open the umbrella of related risk factors. And so our questions are from, from one or two questions in 2012, since 2018, that's broadened out to about 10 questions. Some patients, they like to fill out the, it's a simple questionnaire. Some patients like to fill it out and check the boxes. So what we look at is domestic violence, history of sexual assault, depression, anxiety, alcohol, drug abuse, things, things that may point you in a direction that a patient is self-treating something that they're not identifying as PTSD. Traumatic brain injury is on that same assessment scale. Really, it's, it's any, any event can be perceived as, as a path or a trigger for someone someone that is susceptible. Trying to think of the word startle reflex someone startles easy. It may not be PTSD related, but an abrupt noise upon emergence, for whatever reason, could trigger these same behaviors, because as the medicine wears off and as a patient awakens, it is truly, truly a bridge of involuntary action. We just published in December 21 with the Pennsylvania Safety Authority. The editorial direction that we received as a team, and also with Matt, you know, their research analyst and writer was because we're not research and we are QI, and they are purely research and best practices, we fell somewhere in between. We had, we had a program that was coming on several years old. Our injury rate was zero. We were seeing, we were seeing bad wake ups, potentially violent behavior, once or twice a week, you know, with real staff injuries in years 2000, or prior to 2017. And, and so it was their editorial direction that they wanted something replicable. They wanted, they wanted our program. They wanted it as a word document. So, so what we published was the nuts and bolts of Project Golden Eagle, the entire medication strategy why these two drugs are bad and why these three drugs are great. And with their hand, it is best practices research based. And with our hand meeting in the middle is we came up with a generic form of Project Golden Eagle. It's the entire preoperative assessment. It's the entire medication strategy. It's the entire lesson plan for the hands on training to teach a staff member how to safely approach or restrain a patient, whether they're violent or nonviolent, you know, to protect themselves as well as protect the patient from, from more harm. And then what basically what that marriage produced was a, a 50 page document that anyone can download it's free. And you could put your name at the top of it you put any name you want on it, and, and it's all plug and play. I didn't see it at the time, but I just think that was brilliant on Matt's behalf and the editorial staff of Pennsylvania Safety Authority to make a how to manual to replicate Project Golden Eagle. The barrier to implementation is really provider preference and experience and culture. I've been an estus for 25 years. And, and these, these two drugs that that it's for said and a gas agent. I remember early in my training and in the first 15 years of my practice when, when I saw emergence to my room. I gave more of those drugs. And it just escalate I just made it worse. You know, and, and it's, it's this cultural. What's a stronger word than habit. It's this cultural attachment to giving what you were trained to do, you know, 510 20 years ago, and knowing that it doesn't work like you give a drug. And then you, and then you're on this train I'll give a little bit more and yet and the behavior just escalates. And so what we're hoping to do as QI is to penetrate that culture to try something different. You know, to, to, to read a little to try a little. And to, I guess, put your neck out a little bit to not use these two drugs, but use these two drugs. And I don't have a financial interest in any of this. But it's just a proven strategy to improve outcomes. And our biggest barrier is, is experience and culture. An assessment question cost you nothing. It's a simple question. You know, any history of PTSD for any cause. Or sleep disturbances. And if it's a yes or a maybe, then you can ask about a history of domestic violence or sexual assault or depression anxiety, these related risk factors. That would make you believe that this patient would benefit from project on you. And so, so on the front. It's, it's minutes worth of an added assessment. And some people won't make or take that added minute. I think it needs to change that culture and just to add something to your habit of assessing a patient. The other side of that is implementation of a medication strategy. And, and that requires a little more. A little more effort on our part to change the attitude of a practitioner. That's been giving a drug or two or has a, has a very good reason to treat patients with a benzodiazepine to calm them preoperatively or on the onset of potentially dangerous behavior to use that same drug. And the, the medazoline to in the hopes to calm that behavior when in fact the research bears out that it's that same drug that traps that patient and in that event in that episode in that nightmare in that flashback. And, and now you've limited your options who potentially escalated the behavior from maybe nonviolent hysterical to violent and thrashing. So there's a greater potential for self harm or staff harm. And so it's, it's a matter of, of culture and, and doing a little bit of research, a little bit of reading and saying, you know, maybe even try something new, rather than something old that I've been doing for 1015 20 years.