Vasectomy (Male Sterilization) Session VI: Emergency Preparedness This session covers the following topics: What is meant by emergency preparedness What emergency preparedness involves Emergency drugs, supplies, and equipment Examples of selected emergency situations

Session Objectives Objectives By the end of this session, participants will be able to: Describe emergency preparedness requirements for vasectomy and related services List components of emergency preparedness Describe the management of rare emergency situations Display slide Explain: By the end of this session, participants will be able to: Describe emergency preparedness requirements for vasectomy and related services List components of emergency preparedness Describe the management of rare emergency situations Ask if there are any questions, and respond to these as needed.

Emergency Preparedness Administration of pain management drugs, client with other medical conditions may develop life threatening complications Vasectomy is a simple and safe surgical procedure. Surgical team should be prepared at all times to manage such emergencies Display slide Explain: All facilities that provide vasectomy services or that perform other major or minor surgical procedure must have an emergency management and preparedness plan in place. Although prevention of such unlikely events is key, such facilities should have all relevant equipment, supplies, and skilled staff to manage an emergency situation—or at least have the capability to stabilize the client before referral to a facility that has the capacity to handle such cases. Because of the administration of pain management drugs and or as a result of the presence of coexisting medical conditions, some clients may (although rarely) develop complications, even when undergoing a simple and safe surgical procedure such as vasectomy. In most instances, the problem begins as a minor complication, but if it is not addressed promptly, the condition may progress to be life-threatening. The surgical team should be prepared at all times to prevent, detect, and manage such emergency situations.

Emergency Preparedness Involves… Proper client assessment and preparation for the procedure Prevention of intraoperative and postoperative complications Routine, regular monitoring of the client’s condition Availability of emergency drugs and equipment in the procedure and recovery area or rooms Availability of providers skilled at recognizing early signs of complications that may be life-threatening and able to call for assistance and at the same time initiate emergency action A surgical team (the surgeon and his assistant) with the ability to initiate cardiopulmonary resuscitation and stabilize the client before transfer for specialized care Mechanisms in place for routinely assessing the emergency kit or equipment, drugs, and supplies Display slide Explain: Ask: What does emergency preparedness involve? <Allow the participants to respond to the question, and have one of the co-trainers write all of the responses on a sheet of flipchart paper.> Explain Let us now look at this list of what emergency preparedness involves: Proper client assessment and preparation for the procedure Prevention of intraoperative and postoperative complications Routine, regular monitoring of the client’s condition Availability of emergency drugs and equipment in the procedure and recovery area or rooms All emergency equipment must be immediately available, prepared for use, and in good functioning condition. A battery-operated light source should always be available for back-up or focused illumination of the operative site. Availability of providers skilled at recognizing early signs of complications that may be life-threatening and able to call for assistance and at the same time initiate emergency action A surgical team with the ability to initiate cardiopulmonary resuscitation and stabilize the client before transfer for specialized care Mechanisms for routinely assessing the emergency kit or equipment, drugs, and supplies.

Emergency Preparedness Involves..(cont.) A supervisory system that conducts regular emergency drills with surgical teams to determine providers’ responsiveness to different emergency situations Staff (the surgical team) who are highly knowledgeable about the drugs used and who periodically refresh their knowledge Establishment of an effective referral system For mobile or outreach vasectomy and related services, highly skilled providers, fully equipped with supplies and equipment and back-up support Display slide Explain: A supervisory system that conducts regular emergency drills with surgical teams to determine providers’ responsiveness to different emergency situations. Limitations or weaknesses identified must be promptly addressed through trainings or replacement/purchase of required resources. Staff (the surgical team) who are highly knowledgeable about the drugs used for vasectomy and for any emergency situation and who periodically refresh their knowledge on these drugs Establishment of an effective referral system for transferring emergency cases that cannot be managed on-site For mobile or outreach vasectomy and related services, highly skilled providers, fully equipped with emergency supplies and equipment and with established referral links to selected local back-up facilities (Those facilities must have the relevant equipment, instruments, supplies, and trained staff required to handle complications following vasectomy.)

Emergency Trolley Intravenous fluids Sterile gauze Ambu bag IV fluid giving set Assorted emergency drugs Display slide Explain: This slide shows an emergency trolley assembled for use in the procedure area or in the recovery area/room. Emphasize that even in routine settings, it is important to have the emergency tray in place. Refer participants to Handout # 16 and review the list of emergency equipment, drugs, and other supplies and when or in which emergency situation they should be used, as presented in the handout. Inform the participants that such emergency equipment and supplies are now commercially available as kits that can be easily carried around, especially for outreach services, but that also can find application at static facilities. Ask the participants to share their experiences on how their workstations are prepared to manage emergencies, particularly when performing minor surgical procedures such as vasectomy.   Allow some time for questions and comments, and respond to these as needed. Adhesive tape Tourniquet Syringe and needles Source: Adapted from EngenderHealth 2016

Rare Emergencies (1) Condition Possible causes Signs and symptoms Treatment Prevention measures Hemorrhage (excessive) Undiagnosed coagulation disorders Poor surgical skills Failure to achieve hemostasis Weakness, Restlessness Complaining of thirst Rapid respiration Tachycardia Low blood pressure Identify and ligate or cauterize bleeders Start IV line and give IV fluids with wide-bore cannula May require blood transfusion if bleeding is excessive Proper client evaluation for eligibility and making special arrangements as needed Gentle surgical technique Display slide Explain: Vasectomy is a simple procedure, and emergencies are very rare. However, if in unskilled hands, a client may experience significant bleeding. In most instances, this will not be life threatening, but if it is not promptly managed, the client’s condition may deteriorate. Excessive bleeding may also occur among clients with a history of coagulation disorders. Signs of excessive bleeding include restlessness, rapid respiration, tachycardia, falling blood pressure, etc. Depending on the cause of the hemorrhage, it is important to identify the bleeders and ligate or cauterize them. If the bleeding is excessive, start intravenous fluids and take blood for cross-matching. Monitor vital signs. Such situations may be prevented by doing proper client evaluation to identify conditions such as coagulation disorders and refer clients for specialized care, and by using gentle surgical techniques, especially when stripping the fascia to avoid severing the testicular artery.

Rare Emergencies (2) Condition Possible causes Signs and symptoms Treatment Prevention measures Lidocaine toxicity (rare) Injection of anesthetic directly into vessel Confusion Slurred speech, Restlessness, Tinnitus Twitching, Convulsions, Arrhythmias, Cardiorespiratory arrest Death No antidote Symptomatic Control convulsions, Assisted respiration if respiration is depressed, Refer to facility with capacity to provide specialized care and life support Aspirate to ensure the needle is not in a vessel before infiltration of tissues with lidocaine. Infiltrate slowly. Use the newer jet injections, which administer a lower dose; eliminates risks of toxicity Lidocaine toxicity is rare. It may occur if the recommended dosage of 4–5 mg/kg is exceeded or if the anesthetic (5 ml of 2%) is rapidly injected into the vessel. The signs of toxicity include tinnitus, restlessness, confusion, slurred speech, twitching, convulsions, and cardiac arrhythmias; in severe cases, respiration is depressed, and if it is not attended, it may lead to mortality. There is no antidote for lidocaine. Lidocaine toxicity is an emergency. Steps include controlling convulsions, ensuring that the client is breathing, and initiating cardiorespiratory resuscitation if there is evidence of respiratory depression or cardiac arrest. The patient may need referral to sites with high-dependency and intensive care facilities to manage such complications. To prevent such emergencies, when infiltrating the local anesthetic, always ensure that the needle is not in a vessel, by aspirating it before injecting the local anesthesia. Use of the newer devices that infiltrate anesthesia under high pressure eliminates the risk of lidocaine toxicity. However, such drugs are not readily available and may be costly when compared to lidocaine solution.