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War Games Transcript

Apr 19

Posted by Jeff Young, MD in Clinical Pearls, Discussion, Hospital | No Comments

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

WAR GAMES Session Transcription #1

Clinical War Games Cases

Apr 19

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion | No Comments

In our training program, simulated cases were the key element. The cases were moderated by the “instructor” and the student responded to the data as it was presented. The data that was given to the student is written out in the case spreadsheet, as well as the score for each element in the case. The score for the case was the percent of possible points scored by the student. This allowed us to provide scores and measurement of real improvement (for more information see the how-to manual in an older post).
I have included several cases for you to look at and get familiar with. I encourage you to print them out, and carry out sessions with your students, or with your colleagues. I will also attach a link to several written transcripts of these sessions, so you can get an idea of how the cases flow.
JY
PE
Narcotic overdose
Hypotensive blunt trauma
Asthmatic
AMI

Mental muscle memory…

Apr 5

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information | No Comments

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

Perspective…..

Mar 24

Posted by Jeff Young, MD in Clinical Pearls, Discussion, EMS, Hospital | No Comments

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.

Fast and slow thinking…

Mar 10

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information | No Comments

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.

Here is the lecture on Tactical Decision Making I give to the medical students:

Feb 27

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information, Misc | No Comments

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.

New_War_Games_Lecture_1a

JY

Clinical Brain Training How-To Manual

Feb 21

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital, Information, Misc | No Comments

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

Practice, practice, practice….

Feb 21

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Discussion, EMS, Hospital | No Comments

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

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, EMS, Hospital | No Comments

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.

Mental Status Changes in a Hospital Patient

Feb 7

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, Hospital | No Comments

When you’re dealing with a patient with an acute neurological change, you need to use an organized approach to insure you’re not distracted, and that you rule in or out some simple causes before they cause permanent neurologic damage (such as hypoxia and hypoglycemia). First, focus on the things that could kill the patient from a neurological perspective immediately. Do your ABC’s and then immediately check their pupils, do a rapid neurological exam to make sure they’re not grossly focal and once you’ve done that, you should quickly check if it’s something correctable.
Some key questions in your brain should be:
• Is there evidence of a focal change (blown pupils, hemiplegia, etc.) pointing you toward an acute vascular event.
• Could this be due to medication? What meds have they gotten in the last hour. If the medication record indicates that the patient received 8 milligrams of Morphine 15 minutes ago, and this was a high dose for this patient, you should immediately consider giving them Narcan.
• If you are dealing with a trauma patient, you should clear your ABC’s and get an immediate head CT to look for progression of problems.
• Also remember with the new guidelines on glucose control we may be seeing more and more hypoglycemic episodes so it’s a good idea to quickly check their glucose.