All posts for the month March, 2012

There is often a fair amount of conflict between providers of inpatient care, and pre-hospital and ED providers. Granted, that sometimes people are unreasonable and like yelling at people, and that is inexcusable, but outside of that, there are issues where Emergency and Inpatient providers have conflicting perspectives. I think it would be helpful to talk about this a little.
Early in my career as a trauma director, I walked into a trauma alert and saw the neurosurgery resident and EM attending arguing. I asked what it was about and was told neuro did not want the patient sedated, and EM wanted to give Versed to make the patient easier to deal with. Perhaps in too brusque a manner I said “no versed, do what neurosurgery advises” and that was that since at that point the patient was now under my care. We had a discussion about this a few days later with the Chair of Emergency Medicine and the EM attending where they said I was inappropriate and not respectful (perhaps). I said “look, this patient was awake but had an abnormal neuro exam, if we sedate him, then neurosurgery and trauma cant get an accurate neuro examination (we already knew the head CT was abnormal but not operative). If we cant get an accurate neuro exam neuro needs to place an ICP bolt. If we place an ICP bolt we need to give the patient significantly more sedation to get it done, if we place an ICP bolt we get into a bunch of other issues…etc…..etc……etc. So, it made a lot more sense to me not to anything that might sedate the patient, get them to the ICU, and let it be our problem and not do something that is going to make care much more difficult for us in the long run.” They both said “OK, now we undertand, couldnt you have said that then?” and I said I probably should have instead of barking.
Anyway, the moral of this story is that in-hospital providers often do not have a good perspective on what goes on in the field and ER, and pre-hospital providers and EM providers often do not have an accurate grasp of the issues we are dealing with in the ICU. EM tries it’s best to get that perspective by having their residents spend a fair amount of time during their residency on the trauma and ICU services. This helps a great deal, but an EM attending who is 15 years out of residency may have completely lost their perspective on what happens after the patient leaves the ED.
For pre-hospital providers, unless they have an inpatient job, they get very little exposure to care beyond the ED, and I think that is not optimal. I think it is essential that for at least 10-20 hours a year (at a minimum) pre-hospital ALS providers need to spend quality time in the ICUs. They would Ssee how a few minutes of hypoxia in the field essentially eliminates the possibility of a good outcome from severe head injury. Also, a few minutes of poor monitoring of perfusion and deep shock causes a tremendous amount of problems down the road with pneumonia, and multiple organ failure.
I tell people “you can put 90% of trauma patients with femur fractures, pelvic fractures, small spleen and liver injuries on a park bench with a bottle of Dasani within reach and come back 24 hours later and they will still be alive and probably doing just fine” and thats the truth. The gross rate of major trauma patients where optimal Level 1 trauma center care means life or death is 1000 patients per million of population or about 0.1%. Of those, only 7% (or 0.007% of the population of 1 million) present either hypotensive or with coma from a severe head injury. It is very easy to say “look, our system works well for 99% of patients so cant turn everything upside down for 1%” and that used to be a valid argument, but no longer. In 2012 top hospitals are now being held to incredibly high standards. The way I describe it is that a top hospital needs to save every single patient they should save (based on injuries and disease) and must save 50% of patients who would be expected to die in any average hospital. To save that 50%, you cant make big mistakes, or even a lot of little ones. If one of those patients is aspirating pre-hospital, or in the ED and getting hypercarbic because they are not being closely monitored, the chance of saving them drops precipitously. If a patient looked good at the scene but rapidly deteriorated during transport, but that wasnt picked up and treated, it’s really hard to save them if they’ve had 5-10 minutes of a BP of 70mm Hg and no one noticed. More importantly, if a patient spends 2 hours at a community hospital that sees very little trauma because the paramedic thought it would be too much trouble to call a chopper to the scene, there’s not going to be much we can do once they get to us.
The special forces for a long time have stressed that it is imperative for all members of a team to at least understand the job of each other member. With that knowledge, you can facilitate the other persons actions, remove obstacles, get necessary equipment before they ask for it, etc. Knowledge is good (from the Faber college motto) and more knowledge is better. Learning more about what each member of the team faces each day can only improve overall performance and outcomes.

PI is essential in any organization that provides care to patients. I describe the basic philosophy and some of the goals and pitfalls of PI efforts. I also tried to make it as interesting as possible. There’s also some original music from my old band Nightbreeze with Tom Jolly at the beginning and end. Thanks.

Everyone interested in learning how we learn, should read Daniel Kahneman’s recent book “Thinking Fast and Slow”. I have read a great deal of his work before, and I find it amazing to read something that actually explains the way that your brain works. It makes some sense that you can improve the way you make decisions by understand the way you decide.
The book and the generally accepted concept is that we think in two ways, System 1:intuitive (fast) and System 2: slow and deliberate. Much fast thinking occurs without our awareness of the process. This includes deciding someone in the lane next to you on the highway is about to do something stupid, realizing someone on the phone with you is angry, etc. Slow thinking is the reasoning and weighing of options that we traditionally associate with decision making. In medicine, problems occur when people learn to make bad decisions intuitively, leading to cascades of errors that often leave the person cleaning up with few options.
This is why it is so important to do the following with novice care providers:
1. Make sure you and they agree on the importance of a few basic principles. While it is possible to drill this into someone’s head, even if they don’t accept the reasoning, that is sub-optimal, and that knowledge will probably break down under pressure. Think of anything you have “learned” but that you never really understood (string theory, financial accounting, differential equations, the loop of Henle) and you know that you might be able to figure out the right answer to a question about one of those subjects, but your knowledge is shallow and can get confused very easily. If students don’t understand why airway should come first, it can be dangerous, especially if bad decision processes get ingrained.
2. Practice, practice, practice – you need to bring that intuitive decision making up in the light of day and look at it. The only way is to make people to think fast, and the only way to do that is to put them in situations or simulations that make them think under pressure. We all know it is rare for someone to function effectively in their first high pressure situation, but unfortunately that first high pressure situation may occur with someone’s health and recovery at stake. So its imperative when training to try to determine if your students really “get” it. If they don’t get it, try to figure out why, go through it again, and then look them in the eyes and say “got it now?” and then test them on it one more time. In essence this is what we do on rounds every day, first people do things because we tell them to, then they grudgingly realize that what we say to do makes sense, and then they understand it and teach those things to the next group.
This is also another reason why unneeded variability is so counter-productive. If you do things different ways for no valid reason, people will get confused and think that the process is essentially random. If they get that in their head, it can be difficult to break. We can’t standardize everything, but we should standardize the first 10-15 steps in any algorithm. That way things can get going along a solid path.

It continues to astound me that a vocation that has been around as long as medicine has, continues to have so many unknowns. We don’t know the best way to teach new clinicians, the best way to measure quality, the best way to measure outcomes, or even a viable consistent method to compare clinical care between practitioners and institutions.
This is certainly not from lack of effort, but it does exemplify the incredible complexity of medical care, and the difficulties inherent in trying to teach people to effectively deliver a service with consistent results.
A big part of the issue is that “optimal” care is such a moving target. Optimal care both in and out of the hospital has changed so many times for several conditions that it really makes you wonder if what we are doing now will not be found to be detrimental in the future. ACLS and BLS are great examples of entities taught with absolute certainty 20 years ago, that now have almost entirely different care processes in 2012.
I think this is a very strong reason for decreasing the amount of factual information we ask our students to learn, and increasing the amount of tactical thinking they do. I think there is about a 0% chance that any medical textbook’s information will not be changed significantly in the next 10 years. So drilling that information into student’s heads will lead to knowledge with a potentially very short half life. However, running students through scenarios where they can identify their knowledge gaps, and then fill them, I believe, will lead to better clinicians in the future.
I did research in education for several years, and was amazed at how much was known about learning that had not made it into medical education. Only in the past 1-2 years have many medical schools begun to embrace some of this information, but we still have no good data to know if those changes are helpful.
Textbooks and multiple choice tests work well for teachers and schools because they allow teachers to give standardized tests, with standardized responses, that generate a bell curve of apparent competence. However, as the military and aviation learned, you cant have someone who knows 85% of what to do and pronounce them competent. 85% of the knowledge of how to land a plane will not work out well. Those domains demand their students to demonstrate 100% mastery of the process 100% of the time, and we should as well.
As students, it is vital that you learn to question the medical knowledge you possess. With the tremendous information access at your disposal, there is no good reason why you couldn’t Google the last 10 peer reviewed papers on diverticulitis within an hour of seeing a patient with that condition. You should then have an intelligent discussion with your teacher about why you are doing things the way you are doing, as long as it doesn’t delay emergent care. In emergent situations, following protocols is vital, but afterwards you should make certain you understand why you did what you did. Any teacher who says “this is the way we do it, because I said so” is not a good teacher, and likely not a very good clinician. Anyone who thinks they can write a care guideline that will be optimal for more than a year is probably deluding themselves. Also, be aware that national guidelines are really the “best guess” of a group of smart and experienced people. That guideline should be where you start learning and understanding what to do, not the end of it.

For years, older doctors have lamented the loss of history and physical examination skills by current doctors. They will point to the large number of labs and tests that are now ordered that could have all been avoided with a good history and physical examination. I say, be careful with that sort of attitude.
History and physical examination provide qualitative data, not quantitative data. That means that the person doing the exam has a great effect on the findings. If you had ten physicians take a history and examine someone with abdominal pain, you would likely get three different diagnoses and plans. Now that’s pretty good actually, at least you are not getting 10 different diagnoses and plans, so I will say the H&P has some discriminatory value. But if you were to draw 10 blood samples from the same patient over an hour, its very unlikely you would see any significant variation, and if you did, it would be a results of something wrong with the analyzer, not the person drawing the labs.
The H&P are wonderful for finding out about a patients medical and surgical history, allergies, medications, and general physical condition, but it has definite limits. Despite all the time spent in medical school on listening and identifying murmurs, no cardiologist in the US would make a definitive valve diagnosis based on what they heard with their stethoscope. They would obtain further confirmatory tests. And certainly no cardiac surgeon would replace a valve based on a physical exam. The purpose of the exam in most patients is to function as a screen. I think most of us can elicit pain fairly well, can identify abnormal skin lesions, identify gross nerve deficits, etc. But would I ever open someone’s abdomen based on a physical exam? Only in two cases, where a wound has traversed the abdominal wall and omentum or bowel is hanging out, or a gunshot wound that has clearly traversed the abdomen. Otherwise we usually get either a FAST or CT. When patients are hypotensive, we have a lower threshold for going to the OR based on the exam, but we still like to see fluid in the abdomen on ultrasound or CT.
Why is this so? Because in previous decades, we accepted a certain error rate as part of medical care. You knew that you couldn’t get tests on everyone so you used the H&P to stratify risk. If the risk was very low on exam, you knew it was likely the patient did not have something life threatening going on, and would return if things got worse (hopefully). In this day and age, missing a major diagnosis and hoping the patient comes back before they suffer irreparable harm is just too risky. We set the bar much lower for getting quantitative (laboratory) and semi-quantitative (radiology) data to make certain nothing is going on. If you have the philosophy that “you need to prove the patient is OK, its not the patient’s job to prove to you they are sick” then you will need to obtain tests to “rule out” conditions frequently. Also, because life threatening problems are rare among your average 1,000 ED patients, your tests are often going to be negative and you will be scolded for wasting money.
We need to get a better handle on what is wasteful testing and what is appropriate. Most of the studies in this area are not good, mostly due to the difficulty in studying this problem. It is also very important to know that physical exam and history taking skills are very user dependent and experience dependent. So a person with 1-2 years of medical experience will not be able to differentiate issues that someone with 10 years experience possibly could.
So be careful, if you think the patient doesn’t look right, or there is disagreement about the physical exam and history findings, get more data.