You killed the patient!

Standard

Since this extremely well written article has been making the rounds, After a quick read, I thought I would offer some observations. Fair warning, I do not have access to the original paper right now. But I have corresponded with the author in the past and his assessment is usually as good as gold.

http://emsbasics.com/2014/07/19/murder-by-checklist/

There is actually so much to say about this article, it is hard to even begin. But I think it is fair to mention that what happened here is not only found in EMS, it is endemic in all of medicine and healthcare. I see it every day, in every (hospital) department I see; everywhere in the world I go.

It should really not be surprising to anyone. First, most doctors and many other healthcare providers are selected for their initial professional schooling by their past academic success. A large part of being successful in school is not mastering the material, it is mastering the system. Permit me to give a personal example on how this plays out?

On my first day of pathophysiology class in medical school the professor (a former emergency doctor who subsequently got a second specialty in pathology) held up a copy of “Pathological Basis of Disease.” She stated that anyone who really wanted to succeed in medicine should read it. SO logically I got myself a copy. It is a very detailed book, it was simply not possible for me to keep up with the class quizzes of covering one complete topic of patho a week. My quiz scores were often barely passing and I even failed a couple of them. But I had my eye set on the final; because in school, it is all about the final. I ended up with a B in the class, despite reading all 3049 pages of the Patho book. I was a bit disappointed to score lower than some of my friends who discovered reading the USMLE review guide was an easy A. To their credit they often tried to encourage me to give up my pursuit of knowledge for better grades. Some days I should have listened. Strangely enough, despite getting lower grades, I am usually the one who gets called for the consult and dish out information and insight which they usually take credit for on their patients.

I don’t regret it though. In fact after that year of school, I was convinced I needed more review because I could not remember it all. So I spent my summer vacation working and teaching in EMS and I read the book again. All 3049 pages.
I like big, thick, books, I have several I have read in their entirety. However, my ability on standardized tests is a bit wanting. I still place a much higher value on knowledge.

But getting back to the point, most providers made it through school identifying concepts. Not only that they did very well in school.

The first thing you hear in residency after you get out of school is “all of that book stuff doesn’t matter, now you will learn what you really need.” I heard this exact same thing when I got out of paramedic school. I have no doubt some of my nursing friends heard the same. However, it is not true, all that school stuff does make a difference. But you have to be taught how to apply it. When you are not, your practice turns into what was so eloquently described as “Murder by Checklist.”
Another thing that creates this situation is not recognizing the difference between a crutch and an excuse. There are all kinds of courses like ATLS, PHTLS, ACLS, PALS, NRP, and a host of others that were designed as crutches for non-experts. However, they are no longer seen as crutches, but as certifications of definitive knowledge. Many of these courses even state in the text they are not definitive knowledge, but that is just the obligatory warning label. A vast majority of people who take these classes actually believe they have learned all they need to know to expertly manage patients. As one of my marital arts teachers liked to say “I taught you everything you know, but not everything I know.” As an instructor for many of these courses, I really wish I could say that to everyone, but then I would get yelled at.

Think about it, I will use ATLS as an example because the first instructor I ever had for it stated as an opening “this class will not make you a trauma surgeon.” You would think it didn’t even need to be said. After all, if you could be a trauma surgeon after a 2 day class, who wouldn’t specialize in that? It sure beats years of other residencies.

But the same holds true for other providers. “In the PHTLS book it says…” “Back in the day when ACLS was hard…” We’ve all heard it. We have taught people all there is to taking care of patients is a formula. A check list. There are even efforts to introduce more checklists into medicine. This is often compared to the aviation industry. Unfortunately, check lists don’t work as well for biological organisms as they do for mechanical devices.

It is impossible to know all there is to know about all aspects of medicine. That is why we have specialists. But we must always remember the difference between having a crutch until we can get an expert and believing that crutch is all that needs to be known or done.

Furthermore, institutional practices and requirements meant to minimize errors if they are well designed rewards the use of check lists; of doing the same thing repetitively. Some even require it. I was at one institution that required a trial of peritoneal dialysis prior to hemodialysis on patients who were septic and had already had necrotic gut surgically removed. This was in order to be reimbursed by insurance! Think about that, a septic patient, the peritoneum surgically opened, and necrosis in the compartment, it meets all the major medical contraindications for the procedure! But the insurance company doesn’t care. It is cheaper and more than a few studies point out just as effective at filtration. (Even though not one of those studies enrolled a patient that met contraindications to the procedure.)
Finally, there is the fact we are not all created equal. We all don’t have the same education, we all don’t have the same ability. We all have good days and bad days. We all get fatigued, stressed, and hungry. Medicine is simply not like fast food. You don’t get the same thing from the same people or place every time. Because medical and healthcare education is designed to measure the minimum requirements, providers will never be equal. You know the joke, “What do you call the person who finishes last in medical school? Doctor.” Not everyone sees the bigger picture. Not everyone has the theoretical knowledge. Not everyone can apply it. Not everyone can improvise. In medicine or any other occupation. So, you get a checklist.

Now let’s examine trauma for a minute because it directly relates to this case? There are relatively few people in medicine who are interested in trauma. In fact almost nobody is. It doesn’t pay particularly well. The patients are not particularly desirable. It is a nights, holidays, weekends, job. Almost nothing goes as planned. Life/limb/death decisions must be made constantly, often with imperfect information. There is never the right or enough working equipment. It affects people between the ages of 1-44 primarily. (Most non-peds providers go crazy when they have to work with kids.) In the modern world, trauma care is localized, so most providers outside of specialists, will not see much of it, much less severe cases. They will not be attuned to the subtle signs and findings. Plus some things I probably forgot to mention.

I will pick on EMS a bit, because despite many EMS providers calling themselves “trauma junkies” they really don’t know shit about it. I must profess…Trauma affects every system of the body, not just the obviously affected tissues. It does things like change metabolism. It involves more than just the acute bleeding event. EMS providers spend almost no time learning about trauma. What they do learn is often outright harmful. What isn’t is no more detailed than what a boy scout learns. It should not be surprising when mistakes like this were made. It should be surprising when they are not!

I really can’t find any fault with the medics at all! “The operation was successful but the patient died.” They were doing exactly what they were trained, ordered, and authorized to do. I know they were not trained to identify and place indirect pressure to the aorta superior to the hemorrhage cite. From the account, I wonder why the on-scene physician did not accompany the medics to the hospital? He clearly had knowledge and skill which the medics could not replicate. Some have suggested the medics didn’t think. Of course they didn’t! Have you ever seen an interview with soldiers or firefighter or police officers that did something crazy that ended up being heroic? The reporter always asks “So what were you thinking?” to which the reply is “I wasn’t I was just doing what I was trained to do.” In a stressful situation, practiced training will supersede conscious or logical thought unless you are trained to think about the why to’s and where fore’s.

If you want to train people to do that, I am all for it. But it will take much more than is given now. I don’t see that happening.

Of course in the interest of full disclosure, this piece was written by the guy who was once formally written up for discipline for “Not sounding panicked enough when dealing with a critical trauma patient.”

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8 thoughts on “You killed the patient!

  1. “They were doing exactly what they were trained, ordered, and authorized to do.”

    I’m going to have to disagree with this statement they actually they failed to follow their training and protocols. As Vince D has pointed out at the original article:

    Any trauma algorithm worth its salt will lead off with the ABC’s (or CAB’s) and immediate life-threats. In this case ‘C’ was handled by external aortic compression. While it’s not standard or even well known, this pressure point was providing hemorrhage control none-the-less. With ‘C’ addressed, the providers attempted to move on down their algorithm. What went wrong, however, is that when the patient decompensated after removal of the pressure point they didn’t perform that basic step of returning to ABC’s – which would have resulted in them re-instituting external aortic compression.

    They discontinued bleeding control to get vitals and start an IV, and didn’t re-start bleeding control despite the patient decompensating every time they stopped.

    I can blame the medics, because they failed to practice the basics and let the patient die.

    • Generally it is accepted that practitioners do not perform procedures they are not trained to do. I know of no medic programs teaching abdominal pressure in order to control bleeding.

      You can really find fault in people not doing something they do not know how to do?

      • Since they were doing it before they decided vitals and an IV were more important, yes, I can find fault.

        Going back to the original article:

        When the scene was secured and paramedics arrived, they took over the task of aortic compression. But every time they interrupted pressure to move him to the stretcher or into the ambulance, the patient lost consciousness again. Finally en route, “it was abandoned to obtain vital signs, intravenous access, and a cervical collar.”

        [Emphasis mine.]

        They were instructed in the technique by a physician while on scene to the point that they were able to both maintain it and reinitiate it during the loading process, and maintain it during the transport. They chose to discontinue it knowing that the patient had degraded every time they discontinued it previously, and then failed to even attempt to reinitiate it when he (entirely predictably) decompensated again, in favor of getting vitals, and IV, and a c-collar.

      • Could I pose a question?

        If I was on-scene and asked you to do something you never seen or heard of before, didn’t agree to go on the transport with you, and in the course of your normal duties, the patient decompensated, would your decision be to go back to what I showed you or to follow the standards you were taught in school, delegated in your protocols, and you were experienced and comfortable performing?

        From my own perspective, If I showed you or asked you to do something you never seen or heard of before, I would have the decency to go to the hospital with you. Especially if what I was doing was working and I know what EMS would likely resort to (which is exactly what we saw here).

      • I would go back to what you had showed me, because I had seen that it worked. I also would not have discontinued it, or been very cautious in doing so, because I had seen the effects of stopping. Also, unless things have changed since I was certified, the use of pressure points is something I was taught and am comfortable doing (though not experienced, due to a lack of calls requiring it). This is simply a new pressure point that requires a slightly different technique.

        The story doesn’t make it totally clear, but I would presume that the doctor who showed them what he was doing also explained what he was doing when he showed them. They saw, more than once, what happened when they stopped it and when they resumed it, and they ignored that. They then failed to go back to what they knew was working.

        From my own perspective, If I showed you or asked you to do something you never seen or heard of before, I would have the decency to go to the hospital with you.

        On that, we can agree – I would hope anyone in the doctor’s position would do the same, and that’s what he should have done. But if those medics aren’t smart enough to figure out that stopping the bleeding takes priority over getting vitals and an IV, and that they needed to go back to doing what stopped the bleeding, then they should be considering a career change.

        On a side note: If they had enough people on the ambulance to do ACLS after the patient coded, then they had enough to leave one person holding pressure while the other(s) dealt with vitals and the IV.

  2. Pressure points are no longer part of the curriculum for hemorrhage control in US EMS and have not been in the better part of 15 years. There are providers who have never even heard of using pressure points. (rather unfortunate in my opinion, but I don’t make the curriculum)

      • Jake,

        If you look at not only EMS, but in emergency and resuscitation education over the last decade, there has been a concerted effort to simplify. While reasons like “easy to remember under stress” and adding “not only what, but why, and how are admirable; the trade off has been trying to avoid substantial increases in time required.

        I suspect this will be the trend for the foreseeable future.

        In most civilized countries, the frequency and severity of trauma declines with time, from year to year there may be spikes, but the trend largely continues down. As such, with the occasional outlier like inner cities, etc., providers can expect to become less exposed and subsequently experienced. The natural reaction seems to be that from lack of exposure (and in no small part education) most providers, whether in hospital or out, simply are neither comfortable nor proficient in diagnostics or treatment. This experience and knowledge gap between local or specialized experts compared to the average provider keeps getting wider.

        There are many obvious and proposed solutions, but unfortunately, the political will does not exist to implement them.

        Many experts in hemorrhage control will actually tell you nearly 90% (a few points either way depending on a given source) is controllable by direct pressure. This is true even in heparinized patients. There are actually a couple of techniques to apply indirect pressure to stop peritoneal and retroperitoneal bleeding, the method mentioned in the article is simply one. Given that the teaching of these techniques in my experience are almost completely confined to trauma and vascular surgeons, I suspect the on scene physician in this case was probably in that cohort, closely related, or managed to pull out an obscure piece of knowledge from their training.

        Back in the day, the abdominal compartment of MAST was actually used to provide this pressure for the purpose of tamponading hemorrhage. I have witnessed on too many occasions to recall a spineboard increasing retro and indirectly peritoneal pressure enough to control hemorrhage and turned fatal immediately upon removal.

        There is no shortage of modern medical devices from splints to chemical bandages to attempt to make up for lack of provider capability (either intrinsic or imposed) which in reality serve no purpose other than to make money taking advantage of this lack of capability.

        Hemorrhage control is actually very simple both in theory and practice. The theory is simply: increase the pressure outside the vessel higher than inside.

        The practicality of it is simply being able to access or focus that pressure to the affected area. There are both surgical and pharm techniques to do it. You can even use combinations of them. Ob/Gyn uses combinations daily.

        Once you deal with the delivery of oxygen you can deal with physiologic resuscitation. I will not type all that here.

        US EMS in particular keeps seeing a removal of old tools and techniques from their education and practice, while at the same time holding ever tighter to myth and dogma. While we may disagree on assigning blame, I don’t really see how this would likely have turned out any other way. I would even speculate something similar will happen again.

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