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.
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
Errors
Feb 2
In next week’s podcast I am going to talk about errors and the common reasons why mistakes are common in clinical care. Today I just want to talk about one cause, misperception.
Misperception is a very very common cause of error, and unfortunately a frequent cause of serious error. This occurs when the care provider does not correctly perceive the true state of the patient. There are many reasons why this happens.
First, the provider may not have enough experience to recognize important cues to the patient’s condition. For instance, they may be taught that MI presents as crushing chest pain radiating to the jaw and left arm, but they are not taught that the presentation of MI is very very variable. Therefore when they see a patient with shortness of breath, and maybe a history of COPD, they immediately attribute the dyspnea to the pulmonary disease and proceed down that treatment path.
Second, they may have what is called “buggy knowledge” (rules or heuristics that they create that are simply incorrect). Examples are: all fever on the first post-op day is from atelectasis, or all post-op patients are wet and need diuretics. They may have been taught sloppily, or may have come up with these rules on their own based on insufficient data.
Third, they may be rushed and do not carry out their evaluation in a systematic fashion. In those cases, they may hurry through their history taking and/or their physical exam (or skip it entirely) thinking that they know what is going on and dont need any more data.
So how do you protect against these perception errors? Well, unfortunately experience is the best treatment. Once you have seen the many ways that serious conditions can present themselves, you gain respect for unusual presentations, and cast your diagnostic net wider when evaluating the patient. You also get confirmatory or “rule-out” labs and studies more often (“yeah, he looks OK but get a blood gas and a chest x-ray anyway, we want to be sure. I once saw a guy who looked just like this have a fatal PE”).
But one thing that can be done is to avoid teaching providers absolutes (things always look like this or that). You need to stress that medicine is a very inexact science, especially outside of the hospital where the whole gamut of labs and studies are not available, and where decisions must be made quickly. Also, it is important to stress a bit of fear that you might be missing something. A good maxim to keep in mind is “it is your job to prove the patient is OK, it is not the patient’s job to prove to you that they are sick”. If you keep that in mind, you will go to that extra step to confirm your perception. That extra step can often be the difference between a good and bad outcome.
JY
In this case, you are presented with a patient who had a recent ERCP for choledocholithiasis. He has increasing abdominal pain, declining BP and urine output, elevated amylase and a CT indicative of acute pancreatitis, here are some points for you to think about, and my take on the issue:
Question: Does the fact that the patient doesn’t look terribly ill important?
Discussion: In some cases yes, some no. As I have said to my residents, any idiot can tell when someone is dying, the good clinician can act on problems before they are obvious. The fact that the patient is not dying just means you have more time to figure things out. If the clinical data indicates something is going on, you need to act.
Question: Do you need a CT and all those labs?
Discussion: The most devastating complication that could be occurring in this case is a duodenal perforation from the procedure. You are not going to be able to rule out that complication on physical exam, so increasing abdominal pain after ERCP warrants CT scanning (or just a flat plate to look for free air, but a CT gives you more useful information). The labs are necessary to get an idea of the status of the organ systems (renal, hematologic, etc.).
Question: Does the patient need to go to the unit?
Discussion: Dont know about your hospital, but in mine, patients at high risk for deterioration should be in the ICU or a very capable step down unit. The acute care floor simply has a nurse to patient ratio that is too high to insure that the patient will be checked on every hour or more. Also you will want a close watch on the patients hemodynamics, urine output, etc.
Question: What about all the other stuff?
Discussion: I believe you need to look for things, not wait for them to present if you have a suspicion that badness is going on. As I’ve said, if you wait, sometimes you will get behind the curve. Remember, if youre worried about costs, its a lot cheaper to look for problems and intervene early than it is to wait till patients crash and then act.
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.
In this podcast, I describe the unique aspects of handling medical emergencies, and give you strategies for how to teach people to function more effectively.
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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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