A discussion of how to begin to change your clinical or emergency service. Thanks for listening. JY
Discussion with Chief Eggleston on “Dealing with Reality”. As a leader, how do handle it when your goals and vision run up against obstacles so great that they endanger your success. We also talk about strategies to win over detractors or drive over them. Thanks for listening.
Starting a series on how to lead clinical teams, whether its a trauma center or a fire department. This part gives the background on what kind of positions are worth taking, and what to do when you show up. Thanks for listening. JY
A discussion with Tom Joyce of Orange County Fire and EMS of several patient care issues. Thanks for listening. JY
A discussion of what has went wrong, and what we need to do going forward in the battle to prevent harm and optimize outcomes in medical care. A little from an original tune I wrote a few years ago and performed with friends. Thanks for listening. JY
A discussion with some examples of the difficult problem or properly risk assessing patients. Thanks for listening. JY
Since the site has been up for around 2 years, nothing I have seen or heard has made me waver from these principles of safe care that I wrote back then. Though they are available on the site, I wanted to put them here on the front page so everyone sees them. Thanks, podcast coming in next 48 hours.
An essential component of Clinical Brain Training is to stress basic principles of care instead of care based on ego, limited experience, and fads. Basic principles are a fundamental concept in all high-risk endeavors. Firefighting, air combat, martial arts, nuclear power, infantry operations, and sports all have these essential principles that are basic to safe, effective performance. They are not all that is needed for effective performance, but without them, effective action is impossible.
The purpose of basic principles is to align the practitioner’s thoughts and actions during high-stress situations. When you have many things that you “can” do, basic principles tell you what you “must” do.
In modern medicine, there is a lack of basic principles. The reasons for this are several. First, there is a general dislike for “cookbook medicine”. This stems from the insecure belief that if you could read how to take care of patients in a book, what do you need doctors for? Second, there is the phenomenon of “ego-based medicine” where many physicians discount research and expert thought in favor of their own experience and beliefs. However, if you analyzed any busy physician’s practice, you would see basic principles emerge, even if they refused to admit they exist.
Thus, we created a system that could: assess the ability to think clearly and efficiently, assimilate clinical data into a diagnosis and treatment plan, and begin to fit the acute situation into the overall patient’s plan of care. We stress basic principles in dealing with acute changes in patients’ condition.
These basic principles are:
• In the hospital, always go see the patient if there is an acute change in their condition. In the field, approach every patient as if they may be sick, if they aren’t, good for them.
• Always have someone gather essential patient history and a medication list
• Always bring help with you into the room of an acutely ill patient
• Always assess the airway, breathing, and circulation first
• It is always better to rapidly control the airway in the very unstable patient
o Have a very low threshold for controlling the airway in unresponsive, or poorly responsive patients
• Always examine the major organ systems, and specific areas of concern
• Always insure you have IV access
• Supplemental oxygen is always a good idea in the acute situation
• For acute mental status changes, check recent medications
• If the patient is truly ill and unstable, cast the net of labs and studies widely until you have stabilized the patient, in the field – get to the hospital immediately
• In the field and in the hospital, think of where the patient will need to go next and gather the resources to make that happen before you need them
• In the hospital, as soon as you have initiated stabilization and diagnosis, call your higher-ups. In the field, when you have started stabilization, get to the hospital, dont wait to see what happens
• Do not send patients to areas where they can not be closely monitored until you have stabilized their airway and overall condition
• A hypotensive post-operative patient is bleeding until proven otherwise
• Pulmonary embolism and myocardial infarction can present as anything from cardiac arrest, to a cough and you can not exclude either condition on physical examination
As far as the issues of cost containment, and husbanding of medical resources, we reinforce safety in all decisions, and not cost-efficiency. We feel the rapid diagnosis and treatment of life threatening conditions will save more money in the long run than a less intense, piecemeal diagnostic and therapeutic strategy. Multiple studies have found that costs are much higher if significant conditions are not acted upon rapidly.
A discussion of a risky process (securing the airway) and the complexities of doing it well, and protecting the patient. Also I’ve attached a picture of my son Andy and I running a medic shift together at CARS.
Thanks for listening. JY
Discussion of paranoia and decision making. What is too risky to ignore, and what is so benign to investigate that you are wasting resources and time. Some of my playing with the band Green Eggs and Sam in Charlottesville from a few years ago. Thanks for listening. JY
Haven’t been on call and have been traveling. Will have it posted by Tuesday. Thanks for visiting the site. JY