All posts for the month January, 2012

In this case, you are presented with a patient who had a recent ERCP for choledocholithiasis. He has increasing abdominal pain, declining BP and urine output, elevated amylase and a CT indicative of acute pancreatitis, here are some points for you to think about, and my take on the issue:

Question: Does the fact that the patient doesn’t look terribly ill important?
Discussion: In some cases yes, some no. As I have said to my residents, any idiot can tell when someone is dying, the good clinician can act on problems before they are obvious. The fact that the patient is not dying just means you have more time to figure things out. If the clinical data indicates something is going on, you need to act.

Question: Do you need a CT and all those labs?
Discussion: The most devastating complication that could be occurring in this case is a duodenal perforation from the procedure. You are not going to be able to rule out that complication on physical exam, so increasing abdominal pain after ERCP warrants CT scanning (or just a flat plate to look for free air, but a CT gives you more useful information). The labs are necessary to get an idea of the status of the organ systems (renal, hematologic, etc.).

Question: Does the patient need to go to the unit?
Discussion: Dont know about your hospital, but in mine, patients at high risk for deterioration should be in the ICU or a very capable step down unit. The acute care floor simply has a nurse to patient ratio that is too high to insure that the patient will be checked on every hour or more. Also you will want a close watch on the patients hemodynamics, urine output, etc.

Question: What about all the other stuff?
Discussion: I believe you need to look for things, not wait for them to present if you have a suspicion that badness is going on. As I’ve said, if you wait, sometimes you will get behind the curve. Remember, if youre worried about costs, its a lot cheaper to look for problems and intervene early than it is to wait till patients crash and then act.

Hope you all found that at least mildly useful. It has always frustrated me that we conclude we cant teach someone how to do something very complex, when we use the same teaching methods that haven’t worked in the past (have them read and then give them a multiple choice test). Or we have them watch others do it and expect by watching 10 people do something 20 different ways, they will somehow absorb the right way.
We need to “harden” as Nate Fick would say (look him up on Wiki) against error. The way to do that is to make absolutely sure they have internalized the process by teaching them, then coaching them, then holding them to a higher standard the next time, then coaching and teaching them again, and then instilling in them a belief that they will never know everything they need to know. The final step is most important, because I feel a sense of “fear” that you will be caught in a situation that you will not be able to handle spurs people to keep constantly alert, and will make them push themselves to get more competent with more complex situations.
Is their research and science to help us? Not really. There is some data to show that adult learners need active learning, where they go out and find answers for themselves, and participate actively in the learning process. But there is very little research in medical care to show what actually creates solid mental processes and what does not. What is pretty well accepted is that those people that want to constantly get better usually do.
In conclusion, I think we need to embed a solid foundation for emergency care in the hospital and pre-hospital. This should include what is generally considered the safest and most effective way to handle the situation. Once you have a curriculum to teach, you should make novices learn the core principles, and make certain you explain the rationale for those principles (wrote memorization without understanding is a recipe for fragile competence, its easy to smash it when things get hairy). But then we need to make sure they are completely competent with each chuck of the evolution (primary survey chunk, secondary survey chunk, initial intervention chunk, etc.) and then after they know those cold, give them the tools they needs to connect the chunks. Sometimes these are little heuristics they can come up with, sometimes these are hints that you will give them. I believe if we teach these life saving complex tasks that way, and continually test them with more and more complex simulations (either cognitive or high-fidelity) we will have better performance.

If a patient is in respiratory distress, go through your initial actions (bring help, ABC’s IV, oxygen) and then focus on the respiratory system. Your first major decision is whether the patient needs immediate intubation or not. Some factors in that decision are:
• Is the patient newly obtunded? If so, intubate
• Can the patient speak? If they can only say 1-2 words without taking a breath, you should prepare for intubation. If there is a quick fix (reactive airway disease and an albuterol treatment) or if theyre sats are maintaining over 92%, you have some time, but you must remain with the patient until things improve
• Are they using accessory muscles, grunting, sweating, and looking tired? Check ABG and CXR stat, and prepare for intubation
Remember if a patient has a fixable problem that requires a procedure (hemothorax, penumothorax, etc.) but exhibit the signs written above, the patient could crash if you give them any sedation. It may be safer to intubate the patient, perform the procedure, transfer to ICU, and re-assess over several hours.

Let’s say you’ve decided not to intubate them, you want to re-examine their lungs, get an ABG, and a CXR. If their CXR looks OK and their ABG shows a poor PO2 and a middling pCO2 you must rule out PE. PE will not always make someone short of breath, it can present in a myriad of ways.

So the algorithm is, if someone is in respiratory distress:
• Do they need to be intubated? – yes, no, maybe.
• Do they or do they not have a mechanical problem within their chest that’s keeping them from ventilating? – Listen to lungs, get stat CXR
• Next, think of the wide variety of things that cause respiratory issues (aspiration, worsening pneumonia, fluid overload from excess input or inadequate urine output, fluid overload caused by an M.I., or most importantly in surgical patients – Pulmonary embolism
o You are not going to be able to rule in or out PE at the bedside (examining their calves usually is of no help). You need to have a high index of suspicion. That index is affected by: are they getting proper DVT prophylaxis, do they have a long bone or pelvic fracture, is this their first time out of bed in 5 days, etc.
We’ll have more on PE in a separate post.

You have to remember, never try to replace a fresh tracheostomy in the ICU, ever.  I don’t care it there’s a suture hanging out and you can see the hole. If you’re in the E.D. and somebody comes in, they’re a chronic trach patient, that’s fine.  But in the unit, for somebody who’s on a ventilator, never, never try to replace a fallen out tracheostomy tube, just orally intubate them and put the trache back under controlled conditions (of course this does not apply if their pharynx and larynx were removed, you may have to try to get that one back in, but if it doesn’t go in easily, and if theyre breathing, put supplemental oxygen over the hole and call for ENT help).
Everybody thinks that when you put a trach in that’s the end of the airway, trachs are put in for convenience unless somebody gets a laryngectomy.  If the trach’s not working you pull it out and you put them back on the ventilator using an endotracheal tube.  Not remembering that has probably led to the demise to quite a few patients, because people just keep messing around with the trach and trying to suction through it and trying to repositioning it and trying to do this and trying to do that. Bottom line, if you don’t think the trache is in the right place, just pull it out, and just go ahead and endotracheally intubate them.  99% of the cases, the trach was not placed because there was a problem with the airway, the trach was placed because you were trying to get them off the vent.  Most important, you’re not going to have a lot of time think in those situations, a lot of times what you can do is just pull the trach out and bag.  Just put your finger over the hole and just bag them.  The other thing you can do in this situation is let the balloon down.  And then see if the patient can ventilate if you were too scared to pull the trach out.  You can let the balloon down and see if there was some problem with that.  A lot of times when that happens the trach is dislodged and is blocking the airway, so until you get the trach out, they’re not going to get any better.

Assisting Respiration and Airway Control:
 When you have somebody with an airway issue, if they don’t have a tube in them, they have to be able to protect their airway, be able to exchange oxygen and release carbon dioxide, if they can’t do that, you need to control their airway.  If you’re uncomfortable controlling their airway, you need to know how to bag mask ventilate patients.  That does not mean hold the mask and press it down on their face and squeeze the bag.  There’s a specific technique that you need to use to bag mask and ventilate someone and you should learn it since it will save someone’s life someday. If you are with an anesthesiologist or respiratory therapist, ask them to show you, and then have them watch you try to do it.

Diagnosing Acute Airway Issues in the Intubated Patient:
If the patient does have an airway, you need to make sure that the path from the outside into their lungs is clear and you need to think about it that way.  So, if they’re unable to ventilate someone and they have an endotracheal tube in, the first thing you need to do is, bag ventilate them and listen to breath sounds.  That will tell you whether the path to the lungs is clear.  If there are no breath sounds, you need to stick a suction catherer down the endotracheal tube to ensure that path is clear.  If that path is clear, you need to make sure there’s not a mechanical obstruction with a physical exam and then a stat chest x-ray.  If the path from the outside to the lungs is clear, and the lungs have no pneumothorax or hemothorax or other mechanical issues, then you need to start thinking about ARDS, severe pulmonary edema, pulmonary embolism, and other intrinsic lung issues.  If that’s going on and the patient can’t be ventilated adequately, you need to quickly get some experienced help to the bedside.  

I honestly don’t know where I got this (it’s a little too eloquent for me to have written it). If anyone recognizes where it came from let me know. Its an excellent analysis of why errors are so common in clinical care.

“Human beings are complex organisms with extremely intricate interactions. In the verbiage of Normal Accident theory, human medicine is an industry with high complexity and loose coupling. The complexity is self-evident, the coupling implies that there are few direct, inviolate interactions in the human system. It also means that there are opportunities for recovery of the organism after failure. As an analogy, a nuclear missile in flight is a tightly coupled system of high complexity. Once in flight, in the absence of a self-destruct mechanism or a competent anti-missile system, the launch will invariably lead to a landing of the missile and detonation. Shooting a gun at a target is a system of low complexity and tight coupling (once the trigger is pulled there are few ways to prevent the outcome), a sailor in a rowboat trying to arrive at a dock is a system of moderate complexity and loose coupling in that there are many variables, and many approaches and recovery strategies.
Thus, when we look at the delivery of clinical medicine, and the high error rate, several paradigms emerge. First, mistakes often result from incorrect modeling. In examinations of medical errors, the root causes often center on incorrect assumptions about the physical state of the patient, and the necessity for further intervention. Also, due to the high complexity of the delivery system, errors abound in communication, accuracy of results, and finally in efficacious decision making and delivery of therapy. So, when we try to ascertain remedies for incorrect modeling, where do we start?
Models are created from several sources: internal biases, knowledge base and experience; available quantitative data (labs, etc.), qualitative data (patient complaints, physical examination, etc.), and finally external sources (communication, time pressure, etc.). In creating an accurate model you would desire: accurate quantitative that reflects the true nature of the physical condition and performance of the organ system, confirmatory qualitative data to reinforce the hypotheses created from the quantitative data, sufficient knowledge and experience to integrate this data into an effective diagnostic and treatment plan, and visualization of therapy and its effect and possible complications.
What has been previously stated is not without controversy. Our belief is that in the acute and critical care environment where quantitative data is readily available and of reasonable accuracy, where the risk of serious consequences is high, and where many treatments are readily available better care can be provided by using the following process:
• setting up qualitative and quantitative filters to indicate abnormal system performance,
• initial quantitative confirmation of the triggered filter ( but with a very low index of suspicion for dismissing the triggered filter since it is based on tenuous data and is not meant to exclude system problems)
• Targeted quantitative examination through labs and studies
• Qualitative confirmation of the hypotheses created on the basis of the quantitative data (with the emphasis placed on the validity of the quantitative data, and not on the ability of the exam and history to dismiss quantitative evidence of poor system performance).
• Creation and implementation of a treatment plan the best incorporates the known data
• Follow-up to insure that the model was correct and that system performance is improving.
The reasons for the dependence on quantitative data are several. First, there is tighter coupling between laboratory data and system performance, slightly looser coupling for radiological or other studies that depend on interpretations, and extremely loose coupling for physical examination and medical history (meaning that if a lab was run 10 times on the same sample, one would expect little variation, however if a history and physical examination was performed by ten different clinicians, there is likely to be significant variability). Remember that when problem solving in any system, one wants to decrease the complexity of the problem and increase the accuracy of the measurement you are using. Possibly the most complex interaction with the loosest coupling is to walk into a patient’s room who is ill and attempt to diagnose and treat their condition solely through the use of qualitative measures. The tightest coupling would be to measure hourly urine output as a determination of renal function.”

This is the first episode for Clinical Brain Training. An introduction, a little music, and a sample case. Hope you like it.
Please go to the discussion page afterwards.

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