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All posts for the month February, 2012

This is the first episode in the series taking the listener from the 911 call all the way to definitive treatment in the hospital. This podcast concerns a cardiac patient and looks at things from the EMS perspective. Guest: Battalion Chief Chip Walker, Albemarle County Fire Rescue. Thanks for listening.

If you intubate somebody and you don’t hear breath sounds clearly on the left side, first thing you should say is, how deep is the endotracheal tube? It it’s at 18 or 16 cm at the lips it probably can NOT be pulled back in an adult, and a main stem intubation is probably not the problem. Most endotracheal tubes will be at 22 to 24 at the lips. So, if you’re going to pull any endotracheal tube back, you need to check where it is first.
Ask “where is it at the lips” and if the respiratory therapist say 16cm, you should think, “I’ve got some breath sounds on that side, and the oxygen saturations are stable (if they’re over 90%), let me get a chest x-ray and see what’s going on. If it’s at 28cm at the lips then clearly, you pull it back.

Next, should you slam a chest tube into a patient who has decreased breath sounds? The simple answer is, not unless they are dying. Remember I do not recommend putting in a chest tube without a chest x-ray unless the patient is moribund or they have clear signs of tension pneumothorax. And clear signs of tension pneumothorax are not the absence of breath sounds on one side. Its tracheal deviation, hypotension, jugular venous distention, etc., and an effect on pulmonary function reflected by a decreased oxygen saturation or increasing end tidal CO2. I do not believe it is logical care if you get called into a room and somebody says, “I’ve got decreased breath sounds on the right side, but their sats are 98%, they’re normotensive, they have a normal pulse” and you just slam in a chest tube. You need to have more data before you do that.

Key Point: You might say, “Youngie, what’s the big deal, its just a chest tube?” My answer is: procedures tend to distract everyone working with the patient! If you have a patient, and you say “I’m putting in a chest tube” you very likely have just taken 2-3 people’s attention off the patient. One person is getting your supplies, the other is setting up the pleurovac and the tray, and you are getting involved in the procedure. I have seen patients code during chest tube placements where there was no pneumothorax or hemothorax because the draping towel was put over their face, and everyone started watching the person who was putting in the chest tube, and didn’t continue the evaluation and treatment plan. Chest tubes can be lifesaving, but a case of true tension pneumothorax is rare (I have only seen about a dozen in 15,000 trauma patients). In a hospital patient, who is not a trauma victim, and who has not gotten a central line attempt recently, it is very likely NOT the cause of their problems.

When you’re dealing with a patient with an acute neurological change, you need to use an organized approach to insure you’re not distracted, and that you rule in or out some simple causes before they cause permanent neurologic damage (such as hypoxia and hypoglycemia). First, focus on the things that could kill the patient from a neurological perspective immediately. Do your ABC’s and then immediately check their pupils, do a rapid neurological exam to make sure they’re not grossly focal and once you’ve done that, you should quickly check if it’s something correctable.
Some key questions in your brain should be:
• Is there evidence of a focal change (blown pupils, hemiplegia, etc.) pointing you toward an acute vascular event.
• Could this be due to medication? What meds have they gotten in the last hour. If the medication record indicates that the patient received 8 milligrams of Morphine 15 minutes ago, and this was a high dose for this patient, you should immediately consider giving them Narcan.
• If you are dealing with a trauma patient, you should clear your ABC’s and get an immediate head CT to look for progression of problems.
• Also remember with the new guidelines on glucose control we may be seeing more and more hypoglycemic episodes so it’s a good idea to quickly check their glucose.

Its fun to be arrogant. Nothing is easier than saying you are better than someone else, and laughing at them when they’re trying to improve. “We don’t need to do that, we already know what we’re doing, hah,hah”. You know what’s funny, reality couldn’t care less if you think you’re great, it only cares if you are great. The ischemic heart muscle downstream from a new coronary occlusion doesn’t care if you say you don’t need to practice ACLS and EKG interpretation because you know that stuff cold and the other organization that trains everyday is just dumb. It only cares if you know what you’re doing. The child stuck in the back bedroom of a house on fire doesn’t care if you think your department is awesome because it has cool new trucks, he only cares if you know how to use those trucks to save his life. The person who’s spleen is shattered doesn’t care if you’re ranked #1 by a magazine, that person only cares if you’re ED knows when to activate the trauma team, that your trauma team knows how to figure out you’re dying, and that you have an immediately available OR and a team that knows how to use it.
How do you know you’re really great? Quantitative data, not qualitative data. What people “think” is only important in customer relations, not patient care. What matters in patient care is your response time, your staffing, your ability to perform tasks right the first time, your mortality rate, and your complication rate among other things. Is quantitative data always right? Nope, but it’s more likely to reflect your true performance than your opinion of yourself.
If your organization denigrates real data or refuses to measure themselves against others, chances are you will never improve, and very likely will get worse. If your organization values data, posts rates of infections and such in the hallways, encourages and congratulates people for getting additional training, uses up their down time with training and practice, examines everything you do and provides information that helps you get better, you’re in the right place. If not, and you don’t see any likelihood of change, work somewhere else.

It is easy to become overconfident in medical and surgical care. There will be times in everyone’s career, whether you are a EMT, paramedic, nurse or physician, where you seem to grasp all the fundamentals of your profession. I put forward, this is the time when you need to work hardest to increase your knowledge and experience.

My first experience with patient care was as an EMT providing basic and then advanced life support. Your first 100 calls or so will include some cases where you are over your head, but you will almost certainly have someone more experienced with you. You will often think in those situations “hey I could have handled that if I was alone”. The very nature of clinical care is that you are not tested every day, there are a lot of easy days, and even some easy weeks or months. There will be many straightforward cases where we joke “it doesnt seem like any neurons need to fire” to take care of things adequately. To be ready when a case comes along that requires advanced decision making and skill, you have to constantly try to find those situations that make you uncomfortable, whether that is getting an airway in a child on a highway at 3AM, or putting in a subclavian line in a 300 pound woman with a massive GI bleed and a pressure of 60. Your mentors cant find these uncomfortable situations for you, they cant read your mind and they don’t know what you have experienced and what you haven’t. You need to constantly think “what if I had to do this in the worst circumstances, could I do it?” and if the answer is no or maybe, go to someone more senior and talk about it, and then ask them to give you some tips on how to get the job done in those circumstances.

Another point in a clinician’s evolution where overconfidence can be harmful is when they know the simple stuff, and move to the intermediate phase of training. At that point, your breadth of experience is actually quite low, but you’ve mastered the simple things and are looking forward to challenges. You may be the highest level resident at night in the hospital for the first time, or be the 1:1 nurse for a very sick patient for the first time, or it could be the first time you are the medic in charge at a complex scene. This is the point where you are moving from calling for help reflexively, to not calling for help and handling things yourself. The major problem in this transition, is that there is usually no competency assessment (I know that outstanding fire and EMS agencies do test people at this juncture, but it is not universal). In medicine, this transition usually occurs on July 1 between the first and second year for internists, and July 1 between the 2nd and 3rd years for surgeons. We don’t routinely “test” your ability to transition, and be certain you possess those cognitive skills you will need, we just move you from one set of tasks to another. Often, you are bored with your novice tasks, and ready for something more challenging. But you dont know what you dont know (or as Donny Rumsfeld would say, you have”unknown unknowns”).

It is vital before this transition to eat a meal with your Chief residents, or experienced nurses or medics (>3-5 years experience) and ask them “what was the hardest situation to handle when you became the decision maker? How did you handle it? What do you wish you had learned before that day arrived? Don’t do this the day after the transition, but a month before, when you will have the time to fill those gaps, and practice those situations with the most risk. But even if you do all that, and think you’re ready, you need to have a low threshold for “loading the boat” when things are not going smoothly. Even if you’ve practiced these new evolutions in your mind, there are always variables in the real world you cant anticipate. The people that know about those variables are the people who have already passed this stage. Their overconfidence has transitioned into competence (hopefully) and you need to use them as a resource. If they don’t want to help, find someone else. If no one in your organization wants to help, work somewhere else.

JY

In next week’s podcast I am going to talk about errors and the common reasons why mistakes are common in clinical care. Today I just want to talk about one cause, misperception.
Misperception is a very very common cause of error, and unfortunately a frequent cause of serious error. This occurs when the care provider does not correctly perceive the true state of the patient. There are many reasons why this happens.
First, the provider may not have enough experience to recognize important cues to the patient’s condition. For instance, they may be taught that MI presents as crushing chest pain radiating to the jaw and left arm, but they are not taught that the presentation of MI is very very variable. Therefore when they see a patient with shortness of breath, and maybe a history of COPD, they immediately attribute the dyspnea to the pulmonary disease and proceed down that treatment path.
Second, they may have what is called “buggy knowledge” (rules or heuristics that they create that are simply incorrect). Examples are: all fever on the first post-op day is from atelectasis, or all post-op patients are wet and need diuretics. They may have been taught sloppily, or may have come up with these rules on their own based on insufficient data.
Third, they may be rushed and do not carry out their evaluation in a systematic fashion. In those cases, they may hurry through their history taking and/or their physical exam (or skip it entirely) thinking that they know what is going on and dont need any more data.

So how do you protect against these perception errors? Well, unfortunately experience is the best treatment. Once you have seen the many ways that serious conditions can present themselves, you gain respect for unusual presentations, and cast your diagnostic net wider when evaluating the patient. You also get confirmatory or “rule-out” labs and studies more often (“yeah, he looks OK but get a blood gas and a chest x-ray anyway, we want to be sure. I once saw a guy who looked just like this have a fatal PE”).
But one thing that can be done is to avoid teaching providers absolutes (things always look like this or that). You need to stress that medicine is a very inexact science, especially outside of the hospital where the whole gamut of labs and studies are not available, and where decisions must be made quickly. Also, it is important to stress a bit of fear that you might be missing something. A good maxim to keep in mind is “it is your job to prove the patient is OK, it is not the patient’s job to prove to you that they are sick”. If you keep that in mind, you will go to that extra step to confirm your perception. That extra step can often be the difference between a good and bad outcome.
JY