All posts for the month April, 2012

I’ve posted a recent med school lecture on some of the problems with medical education, how to learn medical care, and how to handle urgent medical conditions. I think you’ll like it.
Also has some more music from the album Tom Jolly and I put out in the mid-90’s.
Thanks for listening.

In this podcast I begin the series of War Games Training cases. In conjunction with the information on the website ( you can follow me as I go through the cases, explaining how the sessions can be conducted, and explaining my justification for grading and for which actions should be taken from walking into the patient’s room, to delivering the patient to the ICU.
Please let me know if this format is useful by commenting on the website, or by writing
A little sax from a CD I recorded in the 90’s with Tom Jolly in NC is at the beginning and end.

I am attaching am 18 page transcript of a war game session in 2005. It contains about 8 cases and provides a really good guide as to how to conduct these simulations. I would advise to read through the transcript from beginning to end to get an idea of how we do the cases and how they flow. Then look at the spreadsheets I provided in the previous post to see how we give the student the data and move the case along.
I haven’t matched the cases in the transcript to the spreadsheets (although several of the cases in the transcript are provided in the previous post)but will try to do that in the future when I have a little more time.
Consider this post and the previous post as an introduction to the simulation process. We will actually conduct sessions, and go over concepts in future posts and podcasts.
You see in the transcript that we classify the cases as Level 1 and 2.

Level 1 are cases that third year medical students, PGY-1’s, EMT-Is, and EMT-P’s should be able to get through. In those cases, the presenting complaint leads directly to the offending issue.
Level 2 cases are for PGY-2’s and above, CCEMT-Ps, and ICU personnel. In those either critical care issues are discussed, or the presenting complaint does not lead directly to the problem, and the case requires a broader understanding of how problems present and a more thorough understanding of how to work up and treat critical patient problems.

The cases provided in the previous post are all Level 1, I will attach and discuss more Level 1 and some Level 2 cases in the next post.

Hope you find it useful.

WAR GAMES Session Transcription #1

In our training program, simulated cases were the key element. The cases were moderated by the “instructor” and the student responded to the data as it was presented. The data that was given to the student is written out in the case spreadsheet, as well as the score for each element in the case. The score for the case was the percent of possible points scored by the student. This allowed us to provide scores and measurement of real improvement (for more information see the how-to manual in an older post).
I have included several cases for you to look at and get familiar with. I encourage you to print them out, and carry out sessions with your students, or with your colleagues. I will also attach a link to several written transcripts of these sessions, so you can get an idea of how the cases flow.
Narcotic overdose
Hypotensive blunt trauma

Acceptance by deception…what an absolutely fantastic phrase. As much as I try to read everything I can about error and screwups, it is amazing to me I had not run across it until two days ago. I pulled up the Squad Operators handbook for the rescue organization I am working with that was written by an old friend, John Burruss. In the introduction is an excerpt from an article written by Michael Wilbur, a lieutenant for the FDNY in Firehouse magazine. It describes a emergency vehicle crash, and its root causes. He says “It is bad enough that many apparatus operators take risks when driving and many of
those risks are taken unnecessarily. But in this case the operator had little or no training at all with which to take these risks and with nothing in writing what ever occurred as far as training really did not occur in the eyes of the court. For if it is not in writing, it simply did not happen in the eyes of the law. So not only do we have a young man volunteering his time that has ruined his life, we have fellow firefighters and officers that led the driver to this fate.
This is where the acceptance by deception comes into play.”
In essence, my definition would be those practices that you put into place in your organization, that you know are sub-optimal (or even dangerous) and yet you find reasons to rationalize to yourself and others that “it’ll be fine, stop whining”. This applies to training (“continuing ed is a waste of time, can’t we just say that you did it?”), release of drivers, medics, and hospital personnel (“look we need people working, some training and experience is better than none, or having no one working that shift, isn’t it?”), analysis of error (“sh*t happens, its a one-off”), corrective action (“look we don’t need to do all that, we don’t have the funds, just try harder next time”), etc., etc.
It’s possible that acceptance by deception may be the single greatest cause of mediocre performance, and error that exists.

Think about it.

Mental muscle memory is one the most important things to cultivate when you are learning clinical medicine. It is the process of training yourself to respond in certain ways to certain stimuli. Even if you are facing a completely novel situation, mental training will allow you to carry out the essential tasks in the evaluation without wasting mental energy, that way you can devote all your attention to the novel signs, symptoms, and hazards that you are encountering.
Fire and EMS often do this much better than we do in the hospital. It is rare that a medical student or intern is taught “here are the five things you need to do every time you are in a clinical encounter”, or “when placing a femoral line these are the seven steps you need to carry out to do this safely”. Often in medicine, we tell novices to “watch this a few times”, and then “give it a shot”. If the mentor is good, they will talk about all the steps they are taking to carry out the procedure or encounter, and make certain that the novice understands all the steps. The next step is often not taken, and that is then asking the novice to “talk through” the entire procedure by themselves before they move onto another task. This last step is essential to creating muscle memory, and essential to learning, and it is often not done.
It is puzzling that these educational exercises are not an intrinsic part of the educational process for physicians, and I think if we are going to move to a safer medical culture, they will need to be. In many ways, physicians often have an irrational resistance to any attempt to “cookbook” medical care. I think for many physicians that trained in the 70’s and 80’s they may be a lost cause at this point, since these attitudes are pretty ingrained. But we need to make certain we do not allow these attitudes to gain a foothold in younger physicians.
Here are some muscle memory exercises, and I will put a bunch together for a Kindle offering soon;
1. Step by step account of how to move from recognition of respiratory arrest, to placement of a secure airway. This is probably a 20 step evolution and will often take place under high pressure, therefore it is vitally important to embed these steps.
2. Step by step account of resuscitating a patient with severe medical hypotension. What orders? What labs? Fluids? Antibiotics? Cultures? Etc.
3. Step by step evolution of placing a thoracostomy tube, or a central line

I am not going to write out these steps right now, because people will transfer their disagreement to the steps that I write out, while what I want is for people to realize that the broad concept of consistent clinical thinking is the key, not the individual steps.

ICU patient presentations can be long, arduous, and filled with lots of data, and very little analysis and synthesis. I present a different model for critical care presentations that covers all the important issues, but demonstrates that the presenter is able to pick out important information, analyze and synthesize a response, plan and recommend treatment, and demonstrate the importance of follow up. It also stresses the important concept of risk reduction (removing lines, preventing stomach and skin ulcers, DVT prophylaxis, and activity) adds discussion of these issues routinely to every presentation.
I hope that people will listen and incorporate some of these principles into their current presentations.