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All posts for the month February, 2012

This is a continuation of the case from last week. I discuss some points to consider in preparing for and treating patients in a multiple casualty incident. I also discuss the indications for, and the technique for performing a resuscitative thoracotomy in the ED.

Here is the manual that shows you how to set up simulation sessions similar to what we ran for over 700 students and residents.
The how-to manual tells you the learning objectives, how we construct and present the cases, how to grade responses, and how to provide feedback. Click on the link below and then the same link on the page that comes up to get the PDF file.

Clinical_Brain_Training_How_To_Manual[1]

The entire manual is also available for Kindle for $1 to offset the costs of putting up the website and podcast, but I’m certain you would rather get it for free by clicking the link above. If you want to pay a dollar and get the manual for the kindle, just click on the link below:
Clinical Brain Training How-To Manual
JY

Since I’m working with EMS again, I’ve had to go back and get ACLS. The online Heartcode ACLS product from AHA is a good example of the things I’ve been writing about.
As I’ve told people, I dont think we learn anything without error. We can read things, and think we know them, but until we are forced to bring that information up from memory and apply it correctly, we havent “learned” it. The case scenarios in the online ACLS are a great example of how that works. If you’re bright, and have a good memory, and the ability to pick up things when you read or hear about them, you might be able to pass the scenarios the first time, but chances are you will have guessed on a few things. Guessing and getting the answer right is often a bad thing. This is because you havent learned it, and if that question comes up again, especially under stress, there is probably only a 50-50 chance you will get the correct action.
The great thing about the scenarios is that you go through it, see what you got wrong (which sets it up for learning) and then can run through a similar scenario again (with some changes generated by the program) and face that decision again. Chances are you will say “ooh, I got that wrong last time, I need to do this” and you will (meaning you learned it). Go through similar cases a few times a month, or utilize that knowledge with real patients, and you will have that knowledge for a long time.
When you do brain training scenarios you need to do the same thing. If someone doesnt remember their ABC’s, go back through that part of the evaluation, make sure they understand what they did wrong, and then immediately run them through a similar (not identical) scenario that requires them to do it correctly. If they do better, do one more scenario and move on.
I am going to put a manuscript up that decribes how to do the clinical brain training cases in the next week. Look out for it.
JY

Every clinician in and out of the hospital should have a very regimented way of going in and looking at patients in distress.
First, remember to bring help (a wingman or wingperson) with you. I can tell you from personal experience that it is difficult being in a room with a patient in severe distress and having to leave to get help. If you think you may be stepping into a serious situation, bring someone with you.
In the hospital, it goes without saying, you need to go and see the patient; don’t try to diagnose anything much more serious than a request for Tylenol over the phone. If you get called and it sounds like the patient is coding, you need to tell the nurse, look if you feel you need to call a code you need to go ahead and call it while you’re on your way. Never tell them to wait until you get there (see previous posts on inertia and arrogance).
When you go see the patient you obviously do the ABC’s. The key issue in airway and breathing is to see whether the patient needs to be intubated or not. That’s your decision; you have to think of what you’re looking at, not with respect to the findings but what findings will indicate that you need to move to the next step. These are some of the things we use to determine if emergent intubation is required: can the patient say more than 4 or 5 words in a row? is the patient unresponsive? does the patient have vomit or a jeopardized airway? These are all indications that the patient needs to be intubated. In the case of not being able to talk, you may have time to get an ABG, CXR, and pulse oximetry first, but you should also prepare for intubation. Remember that we’d rather have you intubate somebody than to let somebody get sicker.
To evaluate breathing, you need to rule out the acute causes of breathing problems. Obviously any unequal breath sounds, if you get truly unequal breath sounds, should prompt an immediate examination of the position of the trachea to diagnose tension pneumothorax. If there’s no tracheal deviation, which there usually will not be, you need to get a chest x-ray because it’s very hard to interpret any of those physical findings without one (despite what people might say about fremitus and whispered pectoriloquy, go to Wiki if you don’t know what those things are).
Circulation: check your vital signs, feel the distal pulses, and get a gestalt of the patient’s overall perfusion. Check carotid pulses then move farther and farther from the heart until you are assessing perfusion in the distal extremities. If they have good perfusion in their nailbeds, they are probably OK, for the moment..
Next, make sure everybody has IV access, and make sure everybody has supplemental oxygen. Even if it’s not an indication, in my humble opinion, it’s always right to put them on supplemental oxygen. You should also consider ordering a group of labs and x-rays that you need to get a handle on what is going on. One suggestion is CBC, lytes, Troponin, EKG, ABG and chest x-ray. And often the reason you need to put that into the initial algorithm is that it takes a while to get those things (see post on inertia). A chest x-ray does not magically appear after you call for it, it takes time. So as soon as you see that it’s a sick patient, not something that you can correct pretty quickly, you need to get those things rolling. And the bottom line is that the physical exam is not great for many serious conditions (MI, pneumonia, if somebody’s got something subtle going on in their abdomen, if somebody’s having significant electrolyte abnormalities, and anemia doesn’t show up until it is severe). So worry about saving money tomorrow, if you have a seriously ill patient in front of you, do what you need to do to get control of the situation.

The team response to new trauma patients at trauma centers works on a basic principle, you should have a full response present in the ED (about 10 people including an attending surgeon, 2-3 surgery residents, respiratory therapy, anesthesiology, and even a Chaplain) 30% more times than needed. The reason is that if you only have that response in the ED when you need it, you will either wait too long (until the patient arrives) to activate it (thus not having the resources in place and ready to go when a patient may need them), or you will not activate it when you do need it. This is called overtriage and it is expected in trauma centers. Why? Because in about 10% of cases you will need every one of those resources at the bedside on arrival to save someones life. In our opinion, it is worth overreacting 3 out of 10 times to insure you have the right people at the beside 100% of the time when they’re needed.
Naturally, this can be annoying since many times (30%), you are wasting resources. But we feel its the safest way to do things. This tension between “overreaction” and “let’s just wait and see” is present throughout clinical care, from 911 dispatch to the ICU and beyond. Fire departments also err on the side of having more resources available immediately, than to wait and call them when the situation overwhelms the initial response. The problem with “wait and see” involves the concept in my previous post on inertia. It takes time to call help, have them respond, and figure out how they can help in a high risk clinical situation. It is far easier for everyone to arrive before the patient and assign tasks then. Obviously EMS cant be at the scene before they are needed, but fire/ems often has predetermined plans for delegation of tasks when there are multiple assets responding.
This tension is also evident when you are making diagnoses and initiating treatment in the hospital. As I’ve said in previous writings, any idiot can figure out when someone is dying, the good clinician intervenes before the patient crashes. In order to identify those patients who are beginning to decline, you need a high index of suspicion, and since they are not obviously crashing, you will need labs and studies to obtain data that will demonstrate things are not going on the right direction.
The pressure to obtain less tests and less studies to contain cost often comes into conflict with the desire to make certain that your patient is on the right track. It is a fact of life that when a patient clearly demonstrates they are very sick, it may be too late to save them. Also, despite the costs of additional tests and studies, these costs pale in comparison to the cost of ICU care for someone whose negative trajectory is not detected. Protecting the patient is our first duty, and to protect we must look for problems. Remember it’s not the patient’s job to prove to you they are sick, it is your job to prove they are OK.

TV shows have ruined most medical care providers sense of time. All the way back to “ER” and “Emergency”, people asked for things and they magically and instantly got done. CBC’s, intubation, and IV’s took about 2 seconds to do. Unfortunately reality is different. Inertia (by my definition how long it take to get things done and move forward with care) can be a big problem in emergencies.

On the new podcast Battalion Chief Chip Walker talks about staying one step ahead of the patient and being “active” instead of “reactive”. It is a very very important strategy in emergency care. Next time you’re intubating, starting an IV, central line, chest tube, whatever; have someone time how long it takes from decision to do the procedure..to when it’s done. You will be amazed at how long it actually takes. You dont realize it because you are focused on what you are doing and dont notice the passage of time. In addition, if you dont have the equipment ready to go, and have the mental mindset to get things done rapidly, it can be much worse.

In hyperurgent situations, where what you get done in 1-2 minutes could mean life or death to the patient, deciding to do something that you think takes one minute, but actually takes 10 could be a big problem. One situation I talk about in the podcast is transfering a patient from the prehospital stretcher to the ED bed. Even though you think this can go quickly (and it can if conducted properly) it often takes 2-3 minutes to get the patient ready to move, move them, deal with the lines and cable, get the stretcher out of the room, and then get your first set of ED vital signs. A lot of things can happen in a hyperurgent condition in 3 minutes.

Awareness of the problem is a big part of the solution. If you are cognizent of the fact that things take longer than you think you can make better decisions. For instance, when we have a hypotensive gunshot victim coming in, we will get the OR arranged and then the Chief resident or I will meet the ambulance at the front door. The reason is that I dont want to make a left turn into the trauma bay unless I absolutely have to, and the only reason I would stop in the ED is if the patient’s airway is unsecured and the patient is hypoxic, or they have no pulse, otherwise we go straight to the OR. The reason is that if someone’s BP is 60 systolic, and they are bleeding to death in their belly, realistically it will take 8-10 minutes for me to get into their abdomen and start to get control. Opening up the abodmen in most ED’s is not a good thing to do (my maxim is that you do procedures in the emergency department, and you do operations in the operating room). Operative actions(sewing things shut, clamping and tying vessels, etc.) should be done in the OR since most ED’s dont have the necessary sterility, equipment, lighting and personnel to do this safely, unless they are specifically set up to do it.
JY