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All posts for the month October, 2013

Since the site has been up for around 2 years, nothing I have seen or heard has made me waver from these principles of safe care that I wrote back then. Though they are available on the site, I wanted to put them here on the front page so everyone sees them. Thanks, podcast coming in next 48 hours.

An essential component of Clinical Brain Training is to stress basic principles of care instead of care based on ego, limited experience, and fads. Basic principles are a fundamental concept in all high-risk endeavors. Firefighting, air combat, martial arts, nuclear power, infantry operations, and sports all have these essential principles that are basic to safe, effective performance. They are not all that is needed for effective performance, but without them, effective action is impossible.
The purpose of basic principles is to align the practitioner’s thoughts and actions during high-stress situations. When you have many things that you “can” do, basic principles tell you what you “must” do.
In modern medicine, there is a lack of basic principles. The reasons for this are several. First, there is a general dislike for “cookbook medicine”. This stems from the insecure belief that if you could read how to take care of patients in a book, what do you need doctors for? Second, there is the phenomenon of “ego-based medicine” where many physicians discount research and expert thought in favor of their own experience and beliefs. However, if you analyzed any busy physician’s practice, you would see basic principles emerge, even if they refused to admit they exist.
Thus, we created a system that could: assess the ability to think clearly and efficiently, assimilate clinical data into a diagnosis and treatment plan, and begin to fit the acute situation into the overall patient’s plan of care. We stress basic principles in dealing with acute changes in patients’ condition.
These basic principles are:
• In the hospital, always go see the patient if there is an acute change in their condition. In the field, approach every patient as if they may be sick, if they aren’t, good for them.
• Always have someone gather essential patient history and a medication list
• Always bring help with you into the room of an acutely ill patient
• Always assess the airway, breathing, and circulation first
• It is always better to rapidly control the airway in the very unstable patient
o Have a very low threshold for controlling the airway in unresponsive, or poorly responsive patients
• Always examine the major organ systems, and specific areas of concern
• Always insure you have IV access
• Supplemental oxygen is always a good idea in the acute situation
• For acute mental status changes, check recent medications
• If the patient is truly ill and unstable, cast the net of labs and studies widely until you have stabilized the patient, in the field – get to the hospital immediately
• In the field and in the hospital, think of where the patient will need to go next and gather the resources to make that happen before you need them
• In the hospital, as soon as you have initiated stabilization and diagnosis, call your higher-ups. In the field, when you have started stabilization, get to the hospital, dont wait to see what happens
• Do not send patients to areas where they can not be closely monitored until you have stabilized their airway and overall condition
• A hypotensive post-operative patient is bleeding until proven otherwise
• Pulmonary embolism and myocardial infarction can present as anything from cardiac arrest, to a cough and you can not exclude either condition on physical examination

As far as the issues of cost containment, and husbanding of medical resources, we reinforce safety in all decisions, and not cost-efficiency. We feel the rapid diagnosis and treatment of life threatening conditions will save more money in the long run than a less intense, piecemeal diagnostic and therapeutic strategy. Multiple studies have found that costs are much higher if significant conditions are not acted upon rapidly.

A discussion of a risky process (securing the airway) and the complexities of doing it well, and protecting the patient. Also I’ve attached a picture of my son Andy and I running a medic shift together at CARS.

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Andy and I running a medic shift at CARS. Hopefully he’s the first of my five kids I get to do this with.

Thanks for listening. JY

Discussion of paranoia and decision making. What is too risky to ignore, and what is so benign to investigate that you are wasting resources and time. Some of my playing with the band Green Eggs and Sam in Charlottesville from a few years ago. Thanks for listening. JY

Been thinking about this concept today when trying to figure out where you spend your time and resources to harden your system. At least in medicine, in most processes, it’s a team sport. In those instances, it is unlikely that a single bad decision by a single person will go unnoticed and uncorrected. For example, if you post a patient for surgery who is far too sick to survive the operation. In academic medicine, the resident will see the patient and will likely ask you to explain why the patient needs the operation. Then the pre-op center (which almost every hospital has in one form or another) will evaluate the patient and throw a flag. Then even if they get by that, on the day of surgery the patient will be seen by a pre-op nurse and an anesthesiologist,who all can stop the process. Finally there is the operative team and the time out as final checks before you proceed.

Even in emergency surgery, there is an Emergency Medicine physician, anesthesiologist, and surgical team laying eyes and hands on the patient who can stop a bad decision. In the course of an operation, a single person can certainly cut the wrong thing and cause problems, but as far as cutting something and no one noticing, it is possible, but unlikely. If you cause bleeding, everyone will notice, if you do something else, your surgical assistant will notice, the scrub nurse or tech, and possibly the anesthesiologist, not to mention all the post-op care the patient will receive where it can be discovered.

So when you look at our systems, there are really only a few places where a single error by a single person can resonate, and that is at off hours when staffing is low. In those cases a single nurse or respiratory therapist could be caring for more patients than during the day, and could gloss over significant findings. Since there is no one checking after them until the morning, the error can propagate. An on-call physician can also make a serious error, but there is the safety measure of a nurse at the bedside that can protect the patient from the error, and an escalation of care system that can bring more senior people to the bedside to re-evaluate. That is why empowering the nurse to speak up, and empowering everyone to call for more help is vital.

As I’ve said before, the difference between medicine and other high reliability industries is medicine’s proclivity for putting people alone into high risk situations. Fire has the company officer always backing up the firefighter, the military always has the corporal and sergeant, and aviation (in most cases) has a co-pilot and avionics to alarm and intervene. In medicine we need to get back the experienced charge nurse whose only duty is to look out for the safety of their patients, and set tripwires for problems where if the data is consistently abnormal, the information is spread across the providers wide enough to insure that an adequate response occurs.