Jun 26
Review of definition, recognition, and treatment of shock. I go over some of the rationale for resuscitation from the military, and the usefulness of measuring lactic acid when triaging injured patient. Thanks for listening. JY.
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For my lecture on airways, and surgical airways. Go back to airway podcast for more information.
JY
Airway
In my opinion, you should try to do EVERYTHING in the back of the ambulance (you are one step closer to the hospital if things go south)
Jun 15
Very interesting paper in New England Journal of Medicine (NEJM 2009;361:1368-75, Variation in hospital mortality associated with inpatient surgery) that hospitals have widely variable mortality rates, but surprisingly very similar complication rates. What seems to differentiate great hospitals from good ones, is the ability to rescue patients from complications, not preventing complications.
This is a very important finding, because rescue, in hospitals, is often neglected. We assume that the same nurses and staff that perform routine daily medical care, can immediately transition into providers that can handle the rapidly changing variables present in a patient who is declining or crashing. Often saving a patient with a major complication requires aggressive resuscitation, thorough and rapid search for a cause, and immediate intervention. Another problem is that these patients often look “sick” but dont look like they are “dying”. By the time they look like they are dying, it is often too late to effectively intervene.
Also you could gather 10 patients with sepsis, and they will all have different symptoms, vital signs, and lab data. It takes an experienced caregiver, with a very healthy paranoia, to intervene correctly in these situations. Another maxim of rescue (in hospital and out) is the acceptance of over-reaction. I have talked about this before in that the fire-ems community accept a rather large percentage of calls where they “over respond” based on the eventual facts of the situation. Hospitals are only now learning the importance of over-reaction, and the fact that if you are going to catch the 5 patients who are dying from a complication, you may need to vigorously intervene on the 20 patients who just “look like something is wrong”. Waiting until those 5 patients declare themselves as “really sick” will likely eliminate your opportunity to save all of them. Thus, over-reaction will save lives.
Jun 10
In my ICU, the intensivists agree about almost everythig, except aggressive diuresis. I am happy diuresing people, as long as I know that they are euvolemic. Diuresing a hypovolemic patient will not do any good, because you will end up giving the fluid back (and more) once their pressure drops.
This is why a simple , minimally invasive blood volume monitor is the Holy Grail in many ways. Swan Ganz Catheters will usually give you a valid impression of fluid status, but it is invasive, and crazy in the recoveing patient who’s fluid status is unknown. A test of Lasix is reasonable, but what do you do if you give 20 of Lasix to a diuretic naive patient and get a poor response? Do you double the dose, or do you conclude the patient’s fluid status may be poor and their kidneys are saying “dummy, enough with the Lasix”.
So, if you see someone with low urine output and hypotension, fluid is the treatment, but I just want to make sure you look at the I’s and O’s, you look at the weight, you look at the BUN/Creatinine. A lot of times they get a contraction alkalosis that causes confusion. I’ve seen patients pH get in the 7.5 range solely through diuresis, and though you will never see a good randomized study of this, it cant be good for the patient.
When you’re doing an infectious investigation, and we’re all guilty of not doing this, you really do need to look everywhere. The kinds of patients that we get in the unit continue to be febrile, continue to have white counts, we don’t know why. You need to look at every IV site, you need to do a rectal, make sure they don’t have peri-rectal, turn them to make sure they don’t have an infected decubitus. I can forgive anybody that the first time through you get a chest x-ray, they’ve got an obvious pneumonia, productive sputum, it’s not a big deal if you didn’t strip them and look at everything, but once you’ve had someone who’s been treated for 3 to 4 days with a presumptive diagnosis, they’re still sick, they’re still febrile, they’ve had a big drop in their white count (and remember, a big drop in the white count is consistent with sepsis not with getting better). You need to say, I’d strip them, look all over their skin, I’d look at their old sites. Look at the IV sites, do a rectal, make sure they don’t have peri-rectal, look at them, look at their back and make sure they don’t have a decubitus
Jun 10
I’ve been remiss about keeping posts going on the website, even though I’ve been pretty steady with a weekly podcst. I will try to put more stuff on the site to read, starting today.
This podcast follows the latest blog entry. How do you get the most out of scored evaluation and training scenarios. This training and testing mechanism has become the most important tool in most organizations for teaching and evaluating students and new employees. Using this teaching tool optimally is incredibly important to both the person being evaluated, and to the organization. I present my thoughts on how to get the most out of the process.
Also have parts of an original song I wrote and performed at the beginning and end. Please tell people who you think may enjoy the podcasts and site, up to 18,000 downloads and want to reach as many people as we can.
Thanks.
JY
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