In the era of cost containment, developing explanations for patient’s condition that minimize or ignore contrary data is attractive and very dangerous. This podcast outlines the issue, and presents some solutions to combat minimization. Thanks, JY.
Podcast: Play in new window | Download
I’ve taken care of lots of patients with life threatening injuries and surgical problems. When I look back and try to figure out what was the key factor in survival, it is keeping the problems one-dimensional.
What I mean is that it is rare to find any single system problem (outside of the heart and the brain) that is immediately and uniformally fatal. What happens is that you get a major abdominal problem, you dont watch kidney function close enough (or react quick enough to changes) and you lose the kidneys, then your fluid balance goes to hell and the patient gets intubated and has worsening vent settings, and so on, and so on.
If I can give one bit of advice from 18 years of taking care of these patients, even if you miss something big and have to do an emergency operation in the middle of the night that should have been done the previous day, you can get the patient over it if you jump on protecting their other organ systems with two feet. That is not the time to diurese them if you are unsure of their fluid status, it is not the time to start narrow spectrum antibiotics, and it is not the time to hold of on intubating them because you think the ABG is not giving you an accurate picture.
The way to get these patients through these episodes is to be over aggressive in protecting the function of the remaining systems. Once you lose the kidneys, go into ARDS, and become coagulapathic, things get much more complicated. Also, remember, do what you neeed to do to protect their remaining organ systems, and this means holding off on procedures and tests that are not central to the problem at hand. If a patient is looking septic, that is not the time to undergo a 5 hour plastics facial reconstruction, unless you think that is central to the infectious problem. Same with ortho procedures and all others. Remember, operations that do not correct your central problem are a physiologic hit to the patient, and it may be one hit too many. These are decisions for the most experienced member of the team, and that should be the attending.
This is a discussion of the algorithms and tactical decisions when you have a trauma patient with a positive FAST. In the podcast, we had a quasistable patient with a positive FAST and a severe pelvic fracture, head injury, and pulmonary contusion. How do you decide what decisions the FAST triggers and what should your reasoning be?
First, remember trauma patients have blood in their belly all the time and the vast majority of them do not go to the OR. In my practice, we admit around 75 blunt spleen injuries, and 90 blunt liver injuries a year, and only around 10% go to the operating immediately for hypotension. The remainder are treated with a non-operative protocol of bedrest and re-evaluation. Of those, around 93% are successfully managed without surgery. So just having fluid in your abdomen, which is what a positive FAST says, does not mean you need to get a laparotomy.
So who does or does not get a laparotomy? Keep in mind we are only talking blunt trauma, penetrating has different algorithms.
An unstable, or recurrently unstable patient with a positive FAST gets a laparotomy, in my opinion. These are patients who present with a SBP<90 who does not increase their BP with fluids (at least 2 liters) and/or blood. If that patient has a positive FAST, then you go to the OR hyperurgently (meaning right now). If that patient has focal neurologic signs, then you need to do your best to rule out a intracranial mass lesion with CT, but that needs to be an attending decision, and the patient needs to be alive (you have more options with a living patient). I once took a patient during residency in this situation to get a head CT with a clamp on their aorta. My attending was not amused. Having a clamp on your aorta is pretty much the definition of unstable, and they cant stop for a head CT. A recurrently unstable patient (or more commonly known as a transient responder) needs surgery. However, in that case, a head CT may be possible with vigorous blood resuscitation, but again, the patient needs to be alive enough to transport.
In this case, we have a quaistable patient (I know many of you have not heard these terms, and we may be the only ones using them). This is a patient with a stable BP, who requires ongoing resuscitation, but whose BP continues to rise and their perfusion improves. To us, this means the patient has bled considerably, but may have stopped, or has a bleed that is worsening when the BP exceeds a certain level. Thus, their perfusion never gets back to normal, but is not worsening. These patients usually have time for CT, but need to be watched like a hawk. We also feel better having big central access and an arterial line. If the patient begins to get unstable, they get pulled off the CT table and go to the OR.
The pelvic fracture adds a big wrinkle. We feel laparotomies are not good for a patient bleeding from pelvic fractures (the Denver group obviously disagrees). This could be a long argument, but I’ll skip it. read the literature and form your own opinion. In this case, you are quasistable with a head injury so you go to CT. You find hemoperitoneum, a minor liver injury, and a major LC3 pelvic fracture with an arterial blush. Angio can kill two birds with one stone in these patients, if you have good access to IR, and good interventionalists (which we have). They can control the pelvic bleeding, squirt theliver and take care of any arterial injuries there, and even squirt the aorta if you didnt have time for a CTA.
Once, again the Chief resident and the Attending should be no more than 20 meters from these patients at any time, and should always keep a close eye on the monitor. If they begin to crash, you may need a new plan. Remember, never let someone bleed to death when you could stop the bleeding in the OR, but also remember, some bleeding can only realistically be controlled by IR.
Add your opinions, nicely.
JY
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.
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
Podcast: Play in new window | Download
As I’ve said in the podcasts and posts, improvising off the top of your head in high risk situations usually doesn’t work out well for anyone. Yet, sometimes you see people respond effortlessly, when circumstances take a rapid turn for the worse, and you think “wow, they can really think on their feet”. There are probably two things going on in experienced people’s minds in those situations.
First, they have been through the situation before, and if you looked at some of the posts, and lectures, you know that when you go through situations multiple times, you create a “model” or “schema” in your head for that situation. That means that your brain goes “ok I’ve been through this, that looks like it did before, that does also, last time I did this and it worked out, I’m going to do that again”. A really experienced person also adds “I’m going to watch out for X, because if that happens, I’m screwing up and I need to change to plan B.”
That works well for people with lots of experience who have worked their way through a lot of situations, what do you do if that’s not you? The key is “mental war gaming” and thinking a few steps ahead, and thinking “what if this is going on?”. Ran a call with the firefighters recently where a child was not responsive after a seizure. I felt the child was OK, but my brain immediately said “check the pupils, check the oxygen sats, and keep a close eye on the breathing” because I’ve been in situations where children have looked OK, but 10 seconds later their lips are blue and they are in respiratory arrest. So if the pupils are equal, the breathing is steady, and the sats are OK, I relax a little. But I also said to myself “what if he stops breathing, or his sats are 80%?” and I began looking for where the bag mask, and peds mask are, where the airway equipment is, and when the transport unit is getting to the scene. You also start playing in your head “if he’s not breathing, what am I going to grab first, are we going to try to ventilate him where we are, or move to a better spot, are we going to let the incoming unit know?, what if we cant bag mask the patient?”, etc.
I was thinking those things, but later I was mad at myself because I was lazy. As soon as I saw that the patient was unresponsive, I should have found the airway equipment, and had it in my or the medic’s hands. I should done that because I also know that if something bad happens, it’s a lot easier to have the stuff you need right in front of you, rather than just thinking “I know what bag that’s in”. This is especially true in the trauma bay since it takes someone else to get the equipment and set it up, leading to an even longer delay. It’s always better in the bay to have the equipment out, on a table, with everything you will need already pulled. Then when you need it you just need to open the packinging and get to work.
Clinical brain training makes you a better provider. Its easy to do on any call or hospital situation, and provides you with constant mental training for when a big situation hits.
Apr 19
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.
JY
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.
JY
Apr 5
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.
JY
You are currently browsing the archives for the Hospital category.
Subscribe in iTunes