Archive for category Clinical Teaching

Basic Principles Reinforced

Since the site has been up for around 2 years, nothing I have seen or heard has made me waver from these principles of safe care that I wrote back then. Though they are available on the site, I wanted to put them here on the front page so everyone sees them. Thanks, podcast coming in next 48 hours.

An essential component of Clinical Brain Training is to stress basic principles of care instead of care based on ego, limited experience, and fads. Basic principles are a fundamental concept in all high-risk endeavors. Firefighting, air combat, martial arts, nuclear power, infantry operations, and sports all have these essential principles that are basic to safe, effective performance. They are not all that is needed for effective performance, but without them, effective action is impossible.
The purpose of basic principles is to align the practitioner’s thoughts and actions during high-stress situations. When you have many things that you “can” do, basic principles tell you what you “must” do.
In modern medicine, there is a lack of basic principles. The reasons for this are several. First, there is a general dislike for “cookbook medicine”. This stems from the insecure belief that if you could read how to take care of patients in a book, what do you need doctors for? Second, there is the phenomenon of “ego-based medicine” where many physicians discount research and expert thought in favor of their own experience and beliefs. However, if you analyzed any busy physician’s practice, you would see basic principles emerge, even if they refused to admit they exist.
Thus, we created a system that could: assess the ability to think clearly and efficiently, assimilate clinical data into a diagnosis and treatment plan, and begin to fit the acute situation into the overall patient’s plan of care. We stress basic principles in dealing with acute changes in patients’ condition.
These basic principles are:
• In the hospital, always go see the patient if there is an acute change in their condition. In the field, approach every patient as if they may be sick, if they aren’t, good for them.
• Always have someone gather essential patient history and a medication list
• Always bring help with you into the room of an acutely ill patient
• Always assess the airway, breathing, and circulation first
• It is always better to rapidly control the airway in the very unstable patient
o Have a very low threshold for controlling the airway in unresponsive, or poorly responsive patients
• Always examine the major organ systems, and specific areas of concern
• Always insure you have IV access
• Supplemental oxygen is always a good idea in the acute situation
• For acute mental status changes, check recent medications
• If the patient is truly ill and unstable, cast the net of labs and studies widely until you have stabilized the patient, in the field – get to the hospital immediately
• In the field and in the hospital, think of where the patient will need to go next and gather the resources to make that happen before you need them
• In the hospital, as soon as you have initiated stabilization and diagnosis, call your higher-ups. In the field, when you have started stabilization, get to the hospital, dont wait to see what happens
• Do not send patients to areas where they can not be closely monitored until you have stabilized their airway and overall condition
• A hypotensive post-operative patient is bleeding until proven otherwise
• Pulmonary embolism and myocardial infarction can present as anything from cardiac arrest, to a cough and you can not exclude either condition on physical examination

As far as the issues of cost containment, and husbanding of medical resources, we reinforce safety in all decisions, and not cost-efficiency. We feel the rapid diagnosis and treatment of life threatening conditions will save more money in the long run than a less intense, piecemeal diagnostic and therapeutic strategy. Multiple studies have found that costs are much higher if significant conditions are not acted upon rapidly.

Securing the Airway (and other heart stopping procedures)

A discussion of a risky process (securing the airway) and the complexities of doing it well, and protecting the patient. Also I’ve attached a picture of my son Andy and I running a medic shift together at CARS.

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Andy and I running a medic shift at CARS. Hopefully he’s the first of my five kids I get to do this with.

Thanks for listening. JY

What’s the Worst That Can Happen?

Discussion of paranoia and decision making. What is too risky to ignore, and what is so benign to investigate that you are wasting resources and time. Some of my playing with the band Green Eggs and Sam in Charlottesville from a few years ago. Thanks for listening. JY

Why we need a bedside ICS

A discussion of the significant need for a tool to organize routine clinical incidents. A little sax section work at the beginning and end. Thanks for listening. JY

Weak Signals and Managing the Unexpected

A discussion of Weick and Sutcliffe’s principles from “Managing the Unexpected” and how they relate to how we design safe systems in whatever we do. Thanks for listening. JY.

Entropy or Why It’s So Hard to Get People to Follow Guidelines

A discussion of why it is so hard to get smart people to control what they do. There is a tremendous pressure toward disorder in the universe, and among physicians, firefighters, and others. It’s one reason why you need to watch what you say around the “kids”.

Chameleon at the beginning and end with Brian Hughley on drums and myself on sax.

Thanks. JY

Transforming Clinical Operations: Lessons From Firefighting Part 1

This is the first part of my Grand Rounds lecture from August 21 on what we need to change in hospital medicine and what we can learn from how firefighting has improved safety and decreased line of duty deaths. Part 2 next week. Thanks for listening. JY

Too much safety?

I realize I am coming to this late, but I just listened to and read about the speech by LT Ray McCormack at FDIC several years ago talking about the safety culture and its detrimental effect on firefighting. I will once again stress I am not a firefighter but I am someone who has worked for 20 years to improve safety and decrease error.

The fundamental friction between the safety culture and experienced clinicians or firefighters is the fact that our process for improving safety is often increasing regimentation, decreasing variability, and standardizing investigations and operations. This is painful for experienced people to deal with, because they have done things by experience and gut feeling for years, often very successfully. Adding these safety processes can slow down operations, increases the number of steps you pass through in carrying out a plan, and in our case increases paperwork, all without adding much value, in the eyes of the experienced and competent provider. For someone who has done a heroic job of teaching people how to do things by applying their own large amount of experience, this is viewed as a waste of time. What I believe the LTs point was that these processes add time without adding value. If you don’t have time to spare, that wasted time could be the difference between carrying out a procedure successfully, or not.

But I would put forward my justification for safety processes. First, people forget things, especially in high stress situations of low frequency. There is no way to insure they remember that safety step 100% of the time other than through procedures. For the person who would never think of not taking that step, the checklist is idiotic. Unfortunately that person isn’t always the person we are trying to protect and we have to design our systems so the most inexperienced and dumb person will do the right thing 100% of the time. All it takes is one miss to cause a catastrophic outcome and that fact has been proven over and over.

What I tell people to do is view the safety procedures as part of carrying out the job, not some add on that is a burden. Stop investing emotions in fighting these safety processes, just learn them, do they efficiently, and move on. They are mostly double checks and are only verifying that you didn’t forget something and when you look at it dispassionately, the amount of time actually added by safety processes is small but the return on that time investment can be large.

Instead use your experience to adapt and revise the safety procedures to be more effective. Improve the education process so young firefighters, nurses, medics, and doctors don’t just learn checklists and mind-numbing routines, but learn WHY we are doing these things. My partner Dr Calland recently said that we should name every page in our guideline and safety manual after the patient whose care prompted the guidelines creation. As in firefighting, many of our guidelines grew from clinical errors and oversights and were built to prevent a recurrence of that problem in the future. We shouldn’t build guidelines and checklists out of every bad outcome, but we should examine every bad outcome to see if our present safety processes are sufficient.

Obtaining Proficiency in Low Frequency High Stress Situations

Discussion of the positives and negatives of experience, and the various tools to use to gain clinical proficiency when actual clinical experience is lacking. A tune I wrote and recorded at the beginning and end. Thanks for listening. I’ve also attached several of the war games scenario sheets we used to train people for these situations.

JY

 

Aspiration resp failure Dyspnea rib fractures AFib Hypotensive blunt trauma

Training: Cognitive, Practical, Tactical

Discussion of training, and the different competencies. Cognitive knowledge (what), Practical knowledge (how), Tactical knowledge (how do I do it when someone is dying in front of me). Thanks for listening. JY