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.
Archive for category Information
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
If a patient is in respiratory distress, go through your initial actions (bring help, ABC’s IV, oxygen) and then focus on the respiratory system. Your first major decision is whether the patient needs immediate intubation or not. Some factors in that decision are:
• Is the patient newly obtunded? If so, intubate
• Can the patient speak? If they can only say 1-2 words without taking a breath, you should prepare for intubation. If there is a quick fix (reactive airway disease and an albuterol treatment) or if theyre sats are maintaining over 92%, you have some time, but you must remain with the patient until things improve
• Are they using accessory muscles, grunting, sweating, and looking tired? Check ABG and CXR stat, and prepare for intubation
Remember if a patient has a fixable problem that requires a procedure (hemothorax, penumothorax, etc.) but exhibit the signs written above, the patient could crash if you give them any sedation. It may be safer to intubate the patient, perform the procedure, transfer to ICU, and re-assess over several hours.
Let’s say you’ve decided not to intubate them, you want to re-examine their lungs, get an ABG, and a CXR. If their CXR looks OK and their ABG shows a poor PO2 and a middling pCO2 you must rule out PE. PE will not always make someone short of breath, it can present in a myriad of ways.
So the algorithm is, if someone is in respiratory distress:
• Do they need to be intubated? – yes, no, maybe.
• Do they or do they not have a mechanical problem within their chest that’s keeping them from ventilating? – Listen to lungs, get stat CXR
• Next, think of the wide variety of things that cause respiratory issues (aspiration, worsening pneumonia, fluid overload from excess input or inadequate urine output, fluid overload caused by an M.I., or most importantly in surgical patients – Pulmonary embolism
o You are not going to be able to rule in or out PE at the bedside (examining their calves usually is of no help). You need to have a high index of suspicion. That index is affected by: are they getting proper DVT prophylaxis, do they have a long bone or pelvic fracture, is this their first time out of bed in 5 days, etc.
We’ll have more on PE in a separate post.
I honestly don’t know where I got this (it’s a little too eloquent for me to have written it). If anyone recognizes where it came from let me know. Its an excellent analysis of why errors are so common in clinical care.
“Human beings are complex organisms with extremely intricate interactions. In the verbiage of Normal Accident theory, human medicine is an industry with high complexity and loose coupling. The complexity is self-evident, the coupling implies that there are few direct, inviolate interactions in the human system. It also means that there are opportunities for recovery of the organism after failure. As an analogy, a nuclear missile in flight is a tightly coupled system of high complexity. Once in flight, in the absence of a self-destruct mechanism or a competent anti-missile system, the launch will invariably lead to a landing of the missile and detonation. Shooting a gun at a target is a system of low complexity and tight coupling (once the trigger is pulled there are few ways to prevent the outcome), a sailor in a rowboat trying to arrive at a dock is a system of moderate complexity and loose coupling in that there are many variables, and many approaches and recovery strategies.
Thus, when we look at the delivery of clinical medicine, and the high error rate, several paradigms emerge. First, mistakes often result from incorrect modeling. In examinations of medical errors, the root causes often center on incorrect assumptions about the physical state of the patient, and the necessity for further intervention. Also, due to the high complexity of the delivery system, errors abound in communication, accuracy of results, and finally in efficacious decision making and delivery of therapy. So, when we try to ascertain remedies for incorrect modeling, where do we start?
Models are created from several sources: internal biases, knowledge base and experience; available quantitative data (labs, etc.), qualitative data (patient complaints, physical examination, etc.), and finally external sources (communication, time pressure, etc.). In creating an accurate model you would desire: accurate quantitative that reflects the true nature of the physical condition and performance of the organ system, confirmatory qualitative data to reinforce the hypotheses created from the quantitative data, sufficient knowledge and experience to integrate this data into an effective diagnostic and treatment plan, and visualization of therapy and its effect and possible complications.
What has been previously stated is not without controversy. Our belief is that in the acute and critical care environment where quantitative data is readily available and of reasonable accuracy, where the risk of serious consequences is high, and where many treatments are readily available better care can be provided by using the following process:
• setting up qualitative and quantitative filters to indicate abnormal system performance,
• initial quantitative confirmation of the triggered filter ( but with a very low index of suspicion for dismissing the triggered filter since it is based on tenuous data and is not meant to exclude system problems)
• Targeted quantitative examination through labs and studies
• Qualitative confirmation of the hypotheses created on the basis of the quantitative data (with the emphasis placed on the validity of the quantitative data, and not on the ability of the exam and history to dismiss quantitative evidence of poor system performance).
• Creation and implementation of a treatment plan the best incorporates the known data
• Follow-up to insure that the model was correct and that system performance is improving.
The reasons for the dependence on quantitative data are several. First, there is tighter coupling between laboratory data and system performance, slightly looser coupling for radiological or other studies that depend on interpretations, and extremely loose coupling for physical examination and medical history (meaning that if a lab was run 10 times on the same sample, one would expect little variation, however if a history and physical examination was performed by ten different clinicians, there is likely to be significant variability). Remember that when problem solving in any system, one wants to decrease the complexity of the problem and increase the accuracy of the measurement you are using. Possibly the most complex interaction with the loosest coupling is to walk into a patient’s room who is ill and attempt to diagnose and treat their condition solely through the use of qualitative measures. The tightest coupling would be to measure hourly urine output as a determination of renal function.”
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