Since I’m working with EMS again, I’ve had to go back and get ACLS. The online Heartcode ACLS product from AHA is a good example of the things I’ve been writing about.
As I’ve told people, I dont think we learn anything without error. We can read things, and think we know them, but until we are forced to bring that information up from memory and apply it correctly, we havent “learned” it. The case scenarios in the online ACLS are a great example of how that works. If you’re bright, and have a good memory, and the ability to pick up things when you read or hear about them, you might be able to pass the scenarios the first time, but chances are you will have guessed on a few things. Guessing and getting the answer right is often a bad thing. This is because you havent learned it, and if that question comes up again, especially under stress, there is probably only a 50-50 chance you will get the correct action.
The great thing about the scenarios is that you go through it, see what you got wrong (which sets it up for learning) and then can run through a similar scenario again (with some changes generated by the program) and face that decision again. Chances are you will say “ooh, I got that wrong last time, I need to do this” and you will (meaning you learned it). Go through similar cases a few times a month, or utilize that knowledge with real patients, and you will have that knowledge for a long time.
When you do brain training scenarios you need to do the same thing. If someone doesnt remember their ABC’s, go back through that part of the evaluation, make sure they understand what they did wrong, and then immediately run them through a similar (not identical) scenario that requires them to do it correctly. If they do better, do one more scenario and move on.
I am going to put a manuscript up that decribes how to do the clinical brain training cases in the next week. Look out for it.
JY
Archive for category Discussion
The team response to new trauma patients at trauma centers works on a basic principle, you should have a full response present in the ED (about 10 people including an attending surgeon, 2-3 surgery residents, respiratory therapy, anesthesiology, and even a Chaplain) 30% more times than needed. The reason is that if you only have that response in the ED when you need it, you will either wait too long (until the patient arrives) to activate it (thus not having the resources in place and ready to go when a patient may need them), or you will not activate it when you do need it. This is called overtriage and it is expected in trauma centers. Why? Because in about 10% of cases you will need every one of those resources at the bedside on arrival to save someones life. In our opinion, it is worth overreacting 3 out of 10 times to insure you have the right people at the beside 100% of the time when they’re needed.
Naturally, this can be annoying since many times (30%), you are wasting resources. But we feel its the safest way to do things. This tension between “overreaction” and “let’s just wait and see” is present throughout clinical care, from 911 dispatch to the ICU and beyond. Fire departments also err on the side of having more resources available immediately, than to wait and call them when the situation overwhelms the initial response. The problem with “wait and see” involves the concept in my previous post on inertia. It takes time to call help, have them respond, and figure out how they can help in a high risk clinical situation. It is far easier for everyone to arrive before the patient and assign tasks then. Obviously EMS cant be at the scene before they are needed, but fire/ems often has predetermined plans for delegation of tasks when there are multiple assets responding.
This tension is also evident when you are making diagnoses and initiating treatment in the hospital. As I’ve said in previous writings, any idiot can figure out when someone is dying, the good clinician intervenes before the patient crashes. In order to identify those patients who are beginning to decline, you need a high index of suspicion, and since they are not obviously crashing, you will need labs and studies to obtain data that will demonstrate things are not going on the right direction.
The pressure to obtain less tests and less studies to contain cost often comes into conflict with the desire to make certain that your patient is on the right track. It is a fact of life that when a patient clearly demonstrates they are very sick, it may be too late to save them. Also, despite the costs of additional tests and studies, these costs pale in comparison to the cost of ICU care for someone whose negative trajectory is not detected. Protecting the patient is our first duty, and to protect we must look for problems. Remember it’s not the patient’s job to prove to you they are sick, it is your job to prove they are OK.
Inertia…the hidden killer
Feb 10
TV shows have ruined most medical care providers sense of time. All the way back to “ER” and “Emergency”, people asked for things and they magically and instantly got done. CBC’s, intubation, and IV’s took about 2 seconds to do. Unfortunately reality is different. Inertia (by my definition how long it take to get things done and move forward with care) can be a big problem in emergencies.
On the new podcast Battalion Chief Chip Walker talks about staying one step ahead of the patient and being “active” instead of “reactive”. It is a very very important strategy in emergency care. Next time you’re intubating, starting an IV, central line, chest tube, whatever; have someone time how long it takes from decision to do the procedure..to when it’s done. You will be amazed at how long it actually takes. You dont realize it because you are focused on what you are doing and dont notice the passage of time. In addition, if you dont have the equipment ready to go, and have the mental mindset to get things done rapidly, it can be much worse.
In hyperurgent situations, where what you get done in 1-2 minutes could mean life or death to the patient, deciding to do something that you think takes one minute, but actually takes 10 could be a big problem. One situation I talk about in the podcast is transfering a patient from the prehospital stretcher to the ED bed. Even though you think this can go quickly (and it can if conducted properly) it often takes 2-3 minutes to get the patient ready to move, move them, deal with the lines and cable, get the stretcher out of the room, and then get your first set of ED vital signs. A lot of things can happen in a hyperurgent condition in 3 minutes.
Awareness of the problem is a big part of the solution. If you are cognizent of the fact that things take longer than you think you can make better decisions. For instance, when we have a hypotensive gunshot victim coming in, we will get the OR arranged and then the Chief resident or I will meet the ambulance at the front door. The reason is that I dont want to make a left turn into the trauma bay unless I absolutely have to, and the only reason I would stop in the ED is if the patient’s airway is unsecured and the patient is hypoxic, or they have no pulse, otherwise we go straight to the OR. The reason is that if someone’s BP is 60 systolic, and they are bleeding to death in their belly, realistically it will take 8-10 minutes for me to get into their abdomen and start to get control. Opening up the abodmen in most ED’s is not a good thing to do (my maxim is that you do procedures in the emergency department, and you do operations in the operating room). Operative actions(sewing things shut, clamping and tying vessels, etc.) should be done in the OR since most ED’s dont have the necessary sterility, equipment, lighting and personnel to do this safely, unless they are specifically set up to do it.
JY
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
Errors
Feb 2
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
In this case, you are presented with a patient who had a recent ERCP for choledocholithiasis. He has increasing abdominal pain, declining BP and urine output, elevated amylase and a CT indicative of acute pancreatitis, here are some points for you to think about, and my take on the issue:
Question: Does the fact that the patient doesn’t look terribly ill important?
Discussion: In some cases yes, some no. As I have said to my residents, any idiot can tell when someone is dying, the good clinician can act on problems before they are obvious. The fact that the patient is not dying just means you have more time to figure things out. If the clinical data indicates something is going on, you need to act.
Question: Do you need a CT and all those labs?
Discussion: The most devastating complication that could be occurring in this case is a duodenal perforation from the procedure. You are not going to be able to rule out that complication on physical exam, so increasing abdominal pain after ERCP warrants CT scanning (or just a flat plate to look for free air, but a CT gives you more useful information). The labs are necessary to get an idea of the status of the organ systems (renal, hematologic, etc.).
Question: Does the patient need to go to the unit?
Discussion: Dont know about your hospital, but in mine, patients at high risk for deterioration should be in the ICU or a very capable step down unit. The acute care floor simply has a nurse to patient ratio that is too high to insure that the patient will be checked on every hour or more. Also you will want a close watch on the patients hemodynamics, urine output, etc.
Question: What about all the other stuff?
Discussion: I believe you need to look for things, not wait for them to present if you have a suspicion that badness is going on. As I’ve said, if you wait, sometimes you will get behind the curve. Remember, if youre worried about costs, its a lot cheaper to look for problems and intervene early than it is to wait till patients crash and then act.
Hope you all found that at least mildly useful. It has always frustrated me that we conclude we cant teach someone how to do something very complex, when we use the same teaching methods that haven’t worked in the past (have them read and then give them a multiple choice test). Or we have them watch others do it and expect by watching 10 people do something 20 different ways, they will somehow absorb the right way.
We need to “harden” as Nate Fick would say (look him up on Wiki) against error. The way to do that is to make absolutely sure they have internalized the process by teaching them, then coaching them, then holding them to a higher standard the next time, then coaching and teaching them again, and then instilling in them a belief that they will never know everything they need to know. The final step is most important, because I feel a sense of “fear” that you will be caught in a situation that you will not be able to handle spurs people to keep constantly alert, and will make them push themselves to get more competent with more complex situations.
Is their research and science to help us? Not really. There is some data to show that adult learners need active learning, where they go out and find answers for themselves, and participate actively in the learning process. But there is very little research in medical care to show what actually creates solid mental processes and what does not. What is pretty well accepted is that those people that want to constantly get better usually do.
In conclusion, I think we need to embed a solid foundation for emergency care in the hospital and pre-hospital. This should include what is generally considered the safest and most effective way to handle the situation. Once you have a curriculum to teach, you should make novices learn the core principles, and make certain you explain the rationale for those principles (wrote memorization without understanding is a recipe for fragile competence, its easy to smash it when things get hairy). But then we need to make sure they are completely competent with each chuck of the evolution (primary survey chunk, secondary survey chunk, initial intervention chunk, etc.) and then after they know those cold, give them the tools they needs to connect the chunks. Sometimes these are little heuristics they can come up with, sometimes these are hints that you will give them. I believe if we teach these life saving complex tasks that way, and continually test them with more and more complex simulations (either cognitive or high-fidelity) we will have better performance.
In this podcast, I describe the unique aspects of handling medical emergencies, and give you strategies for how to teach people to function more effectively.
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