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 Clinical Teaching
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.
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.
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.
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
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.
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.
You have to remember, never try to replace a fresh tracheostomy in the ICU, ever. I don’t care it there’s a suture hanging out and you can see the hole. If you’re in the E.D. and somebody comes in, they’re a chronic trach patient, that’s fine. But in the unit, for somebody who’s on a ventilator, never, never try to replace a fallen out tracheostomy tube, just orally intubate them and put the trache back under controlled conditions (of course this does not apply if their pharynx and larynx were removed, you may have to try to get that one back in, but if it doesn’t go in easily, and if theyre breathing, put supplemental oxygen over the hole and call for ENT help).
Everybody thinks that when you put a trach in that’s the end of the airway, trachs are put in for convenience unless somebody gets a laryngectomy. If the trach’s not working you pull it out and you put them back on the ventilator using an endotracheal tube. Not remembering that has probably led to the demise to quite a few patients, because people just keep messing around with the trach and trying to suction through it and trying to repositioning it and trying to do this and trying to do that. Bottom line, if you don’t think the trache is in the right place, just pull it out, and just go ahead and endotracheally intubate them. 99% of the cases, the trach was not placed because there was a problem with the airway, the trach was placed because you were trying to get them off the vent. Most important, you’re not going to have a lot of time think in those situations, a lot of times what you can do is just pull the trach out and bag. Just put your finger over the hole and just bag them. The other thing you can do in this situation is let the balloon down. And then see if the patient can ventilate if you were too scared to pull the trach out. You can let the balloon down and see if there was some problem with that. A lot of times when that happens the trach is dislodged and is blocking the airway, so until you get the trach out, they’re not going to get any better.
Assisting Respiration and Airway Control:
When you have somebody with an airway issue, if they don’t have a tube in them, they have to be able to protect their airway, be able to exchange oxygen and release carbon dioxide, if they can’t do that, you need to control their airway. If you’re uncomfortable controlling their airway, you need to know how to bag mask ventilate patients. That does not mean hold the mask and press it down on their face and squeeze the bag. There’s a specific technique that you need to use to bag mask and ventilate someone and you should learn it since it will save someone’s life someday. If you are with an anesthesiologist or respiratory therapist, ask them to show you, and then have them watch you try to do it.
Diagnosing Acute Airway Issues in the Intubated Patient:
If the patient does have an airway, you need to make sure that the path from the outside into their lungs is clear and you need to think about it that way. So, if they’re unable to ventilate someone and they have an endotracheal tube in, the first thing you need to do is, bag ventilate them and listen to breath sounds. That will tell you whether the path to the lungs is clear. If there are no breath sounds, you need to stick a suction catherer down the endotracheal tube to ensure that path is clear. If that path is clear, you need to make sure there’s not a mechanical obstruction with a physical exam and then a stat chest x-ray. If the path from the outside to the lungs is clear, and the lungs have no pneumothorax or hemothorax or other mechanical issues, then you need to start thinking about ARDS, severe pulmonary edema, pulmonary embolism, and other intrinsic lung issues. If that’s going on and the patient can’t be ventilated adequately, you need to quickly get some experienced help to the bedside.
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