There is often a fair amount of conflict between providers of inpatient care, and pre-hospital and ED providers. Granted, that sometimes people are unreasonable and like yelling at people, and that is inexcusable, but outside of that, there are issues where Emergency and Inpatient providers have conflicting perspectives. I think it would be helpful to talk about this a little.
Early in my career as a trauma director, I walked into a trauma alert and saw the neurosurgery resident and EM attending arguing. I asked what it was about and was told neuro did not want the patient sedated, and EM wanted to give Versed to make the patient easier to deal with. Perhaps in too brusque a manner I said “no versed, do what neurosurgery advises” and that was that since at that point the patient was now under my care. We had a discussion about this a few days later with the Chair of Emergency Medicine and the EM attending where they said I was inappropriate and not respectful (perhaps). I said “look, this patient was awake but had an abnormal neuro exam, if we sedate him, then neurosurgery and trauma cant get an accurate neuro examination (we already knew the head CT was abnormal but not operative). If we cant get an accurate neuro exam neuro needs to place an ICP bolt. If we place an ICP bolt we need to give the patient significantly more sedation to get it done, if we place an ICP bolt we get into a bunch of other issues…etc…..etc……etc. So, it made a lot more sense to me not to anything that might sedate the patient, get them to the ICU, and let it be our problem and not do something that is going to make care much more difficult for us in the long run.” They both said “OK, now we undertand, couldnt you have said that then?” and I said I probably should have instead of barking.
Anyway, the moral of this story is that in-hospital providers often do not have a good perspective on what goes on in the field and ER, and pre-hospital providers and EM providers often do not have an accurate grasp of the issues we are dealing with in the ICU. EM tries it’s best to get that perspective by having their residents spend a fair amount of time during their residency on the trauma and ICU services. This helps a great deal, but an EM attending who is 15 years out of residency may have completely lost their perspective on what happens after the patient leaves the ED.
For pre-hospital providers, unless they have an inpatient job, they get very little exposure to care beyond the ED, and I think that is not optimal. I think it is essential that for at least 10-20 hours a year (at a minimum) pre-hospital ALS providers need to spend quality time in the ICUs. They would Ssee how a few minutes of hypoxia in the field essentially eliminates the possibility of a good outcome from severe head injury. Also, a few minutes of poor monitoring of perfusion and deep shock causes a tremendous amount of problems down the road with pneumonia, and multiple organ failure.
I tell people “you can put 90% of trauma patients with femur fractures, pelvic fractures, small spleen and liver injuries on a park bench with a bottle of Dasani within reach and come back 24 hours later and they will still be alive and probably doing just fine” and thats the truth. The gross rate of major trauma patients where optimal Level 1 trauma center care means life or death is 1000 patients per million of population or about 0.1%. Of those, only 7% (or 0.007% of the population of 1 million) present either hypotensive or with coma from a severe head injury. It is very easy to say “look, our system works well for 99% of patients so cant turn everything upside down for 1%” and that used to be a valid argument, but no longer. In 2012 top hospitals are now being held to incredibly high standards. The way I describe it is that a top hospital needs to save every single patient they should save (based on injuries and disease) and must save 50% of patients who would be expected to die in any average hospital. To save that 50%, you cant make big mistakes, or even a lot of little ones. If one of those patients is aspirating pre-hospital, or in the ED and getting hypercarbic because they are not being closely monitored, the chance of saving them drops precipitously. If a patient looked good at the scene but rapidly deteriorated during transport, but that wasnt picked up and treated, it’s really hard to save them if they’ve had 5-10 minutes of a BP of 70mm Hg and no one noticed. More importantly, if a patient spends 2 hours at a community hospital that sees very little trauma because the paramedic thought it would be too much trouble to call a chopper to the scene, there’s not going to be much we can do once they get to us.
The special forces for a long time have stressed that it is imperative for all members of a team to at least understand the job of each other member. With that knowledge, you can facilitate the other persons actions, remove obstacles, get necessary equipment before they ask for it, etc. Knowledge is good (from the Faber college motto) and more knowledge is better. Learning more about what each member of the team faces each day can only improve overall performance and outcomes.
Archive for category Hospital
Perspective…..
Mar 24
Fast and slow thinking…
Mar 10
Everyone interested in learning how we learn, should read Daniel Kahneman’s recent book “Thinking Fast and Slow”. I have read a great deal of his work before, and I find it amazing to read something that actually explains the way that your brain works. It makes some sense that you can improve the way you make decisions by understand the way you decide.
The book and the generally accepted concept is that we think in two ways, System 1:intuitive (fast) and System 2: slow and deliberate. Much fast thinking occurs without our awareness of the process. This includes deciding someone in the lane next to you on the highway is about to do something stupid, realizing someone on the phone with you is angry, etc. Slow thinking is the reasoning and weighing of options that we traditionally associate with decision making. In medicine, problems occur when people learn to make bad decisions intuitively, leading to cascades of errors that often leave the person cleaning up with few options.
This is why it is so important to do the following with novice care providers:
1. Make sure you and they agree on the importance of a few basic principles. While it is possible to drill this into someone’s head, even if they don’t accept the reasoning, that is sub-optimal, and that knowledge will probably break down under pressure. Think of anything you have “learned” but that you never really understood (string theory, financial accounting, differential equations, the loop of Henle) and you know that you might be able to figure out the right answer to a question about one of those subjects, but your knowledge is shallow and can get confused very easily. If students don’t understand why airway should come first, it can be dangerous, especially if bad decision processes get ingrained.
2. Practice, practice, practice – you need to bring that intuitive decision making up in the light of day and look at it. The only way is to make people to think fast, and the only way to do that is to put them in situations or simulations that make them think under pressure. We all know it is rare for someone to function effectively in their first high pressure situation, but unfortunately that first high pressure situation may occur with someone’s health and recovery at stake. So its imperative when training to try to determine if your students really “get” it. If they don’t get it, try to figure out why, go through it again, and then look them in the eyes and say “got it now?” and then test them on it one more time. In essence this is what we do on rounds every day, first people do things because we tell them to, then they grudgingly realize that what we say to do makes sense, and then they understand it and teach those things to the next group.
This is also another reason why unneeded variability is so counter-productive. If you do things different ways for no valid reason, people will get confused and think that the process is essentially random. If they get that in their head, it can be difficult to break. We can’t standardize everything, but we should standardize the first 10-15 steps in any algorithm. That way things can get going along a solid path.
Uncertainty
Mar 8
It continues to astound me that a vocation that has been around as long as medicine has, continues to have so many unknowns. We don’t know the best way to teach new clinicians, the best way to measure quality, the best way to measure outcomes, or even a viable consistent method to compare clinical care between practitioners and institutions.
This is certainly not from lack of effort, but it does exemplify the incredible complexity of medical care, and the difficulties inherent in trying to teach people to effectively deliver a service with consistent results.
A big part of the issue is that “optimal” care is such a moving target. Optimal care both in and out of the hospital has changed so many times for several conditions that it really makes you wonder if what we are doing now will not be found to be detrimental in the future. ACLS and BLS are great examples of entities taught with absolute certainty 20 years ago, that now have almost entirely different care processes in 2012.
I think this is a very strong reason for decreasing the amount of factual information we ask our students to learn, and increasing the amount of tactical thinking they do. I think there is about a 0% chance that any medical textbook’s information will not be changed significantly in the next 10 years. So drilling that information into student’s heads will lead to knowledge with a potentially very short half life. However, running students through scenarios where they can identify their knowledge gaps, and then fill them, I believe, will lead to better clinicians in the future.
I did research in education for several years, and was amazed at how much was known about learning that had not made it into medical education. Only in the past 1-2 years have many medical schools begun to embrace some of this information, but we still have no good data to know if those changes are helpful.
Textbooks and multiple choice tests work well for teachers and schools because they allow teachers to give standardized tests, with standardized responses, that generate a bell curve of apparent competence. However, as the military and aviation learned, you cant have someone who knows 85% of what to do and pronounce them competent. 85% of the knowledge of how to land a plane will not work out well. Those domains demand their students to demonstrate 100% mastery of the process 100% of the time, and we should as well.
As students, it is vital that you learn to question the medical knowledge you possess. With the tremendous information access at your disposal, there is no good reason why you couldn’t Google the last 10 peer reviewed papers on diverticulitis within an hour of seeing a patient with that condition. You should then have an intelligent discussion with your teacher about why you are doing things the way you are doing, as long as it doesn’t delay emergent care. In emergent situations, following protocols is vital, but afterwards you should make certain you understand why you did what you did. Any teacher who says “this is the way we do it, because I said so” is not a good teacher, and likely not a very good clinician. Anyone who thinks they can write a care guideline that will be optimal for more than a year is probably deluding themselves. Also, be aware that national guidelines are really the “best guess” of a group of smart and experienced people. That guideline should be where you start learning and understanding what to do, not the end of it.
This is the lecture I give to the medical students here. I usually have to run through it pretty quickly so I thought I’d post it here so you could look at it at your leisure.
JY
Here is the manual that shows you how to set up simulation sessions similar to what we ran for over 700 students and residents.
The how-to manual tells you the learning objectives, how we construct and present the cases, how to grade responses, and how to provide feedback. Click on the link below and then the same link on the page that comes up to get the PDF file.
Clinical_Brain_Training_How_To_Manual[1]
The entire manual is also available for Kindle for $1 to offset the costs of putting up the website and podcast, but I’m certain you would rather get it for free by clicking the link above. If you want to pay a dollar and get the manual for the kindle, just click on the link below:
Clinical Brain Training How-To Manual
JY
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
Initial Evaluation
Feb 15
Every clinician in and out of the hospital should have a very regimented way of going in and looking at patients in distress.
First, remember to bring help (a wingman or wingperson) with you. I can tell you from personal experience that it is difficult being in a room with a patient in severe distress and having to leave to get help. If you think you may be stepping into a serious situation, bring someone with you.
In the hospital, it goes without saying, you need to go and see the patient; don’t try to diagnose anything much more serious than a request for Tylenol over the phone. If you get called and it sounds like the patient is coding, you need to tell the nurse, look if you feel you need to call a code you need to go ahead and call it while you’re on your way. Never tell them to wait until you get there (see previous posts on inertia and arrogance).
When you go see the patient you obviously do the ABC’s. The key issue in airway and breathing is to see whether the patient needs to be intubated or not. That’s your decision; you have to think of what you’re looking at, not with respect to the findings but what findings will indicate that you need to move to the next step. These are some of the things we use to determine if emergent intubation is required: can the patient say more than 4 or 5 words in a row? is the patient unresponsive? does the patient have vomit or a jeopardized airway? These are all indications that the patient needs to be intubated. In the case of not being able to talk, you may have time to get an ABG, CXR, and pulse oximetry first, but you should also prepare for intubation. Remember that we’d rather have you intubate somebody than to let somebody get sicker.
To evaluate breathing, you need to rule out the acute causes of breathing problems. Obviously any unequal breath sounds, if you get truly unequal breath sounds, should prompt an immediate examination of the position of the trachea to diagnose tension pneumothorax. If there’s no tracheal deviation, which there usually will not be, you need to get a chest x-ray because it’s very hard to interpret any of those physical findings without one (despite what people might say about fremitus and whispered pectoriloquy, go to Wiki if you don’t know what those things are).
Circulation: check your vital signs, feel the distal pulses, and get a gestalt of the patient’s overall perfusion. Check carotid pulses then move farther and farther from the heart until you are assessing perfusion in the distal extremities. If they have good perfusion in their nailbeds, they are probably OK, for the moment..
Next, make sure everybody has IV access, and make sure everybody has supplemental oxygen. Even if it’s not an indication, in my humble opinion, it’s always right to put them on supplemental oxygen. You should also consider ordering a group of labs and x-rays that you need to get a handle on what is going on. One suggestion is CBC, lytes, Troponin, EKG, ABG and chest x-ray. And often the reason you need to put that into the initial algorithm is that it takes a while to get those things (see post on inertia). A chest x-ray does not magically appear after you call for it, it takes time. So as soon as you see that it’s a sick patient, not something that you can correct pretty quickly, you need to get those things rolling. And the bottom line is that the physical exam is not great for many serious conditions (MI, pneumonia, if somebody’s got something subtle going on in their abdomen, if somebody’s having significant electrolyte abnormalities, and anemia doesn’t show up until it is severe). So worry about saving money tomorrow, if you have a seriously ill patient in front of you, do what you need to do to get control of the situation.
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
If you intubate somebody and you don’t hear breath sounds clearly on the left side, first thing you should say is, how deep is the endotracheal tube? It it’s at 18 or 16 cm at the lips it probably can NOT be pulled back in an adult, and a main stem intubation is probably not the problem. Most endotracheal tubes will be at 22 to 24 at the lips. So, if you’re going to pull any endotracheal tube back, you need to check where it is first.
Ask “where is it at the lips” and if the respiratory therapist say 16cm, you should think, “I’ve got some breath sounds on that side, and the oxygen saturations are stable (if they’re over 90%), let me get a chest x-ray and see what’s going on. If it’s at 28cm at the lips then clearly, you pull it back.
Next, should you slam a chest tube into a patient who has decreased breath sounds? The simple answer is, not unless they are dying. Remember I do not recommend putting in a chest tube without a chest x-ray unless the patient is moribund or they have clear signs of tension pneumothorax. And clear signs of tension pneumothorax are not the absence of breath sounds on one side. Its tracheal deviation, hypotension, jugular venous distention, etc., and an effect on pulmonary function reflected by a decreased oxygen saturation or increasing end tidal CO2. I do not believe it is logical care if you get called into a room and somebody says, “I’ve got decreased breath sounds on the right side, but their sats are 98%, they’re normotensive, they have a normal pulse” and you just slam in a chest tube. You need to have more data before you do that.
Key Point: You might say, “Youngie, what’s the big deal, its just a chest tube?” My answer is: procedures tend to distract everyone working with the patient! If you have a patient, and you say “I’m putting in a chest tube” you very likely have just taken 2-3 people’s attention off the patient. One person is getting your supplies, the other is setting up the pleurovac and the tray, and you are getting involved in the procedure. I have seen patients code during chest tube placements where there was no pneumothorax or hemothorax because the draping towel was put over their face, and everyone started watching the person who was putting in the chest tube, and didn’t continue the evaluation and treatment plan. Chest tubes can be lifesaving, but a case of true tension pneumothorax is rare (I have only seen about a dozen in 15,000 trauma patients). In a hospital patient, who is not a trauma victim, and who has not gotten a central line attempt recently, it is very likely NOT the cause of their problems.
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