Monday, July 30, 2007
A dead patient arrived late on Saturday and I initiated resuscitation. It was the wrong call.
The history: the patient, in her 80s, had been found collapsed. She had been leaning to one side and she had facial asymmetry. She had been collapsed for an indeterminate period of time and it was ten minutes between being found and the paramedic crew arriving on scene.
On arrival on scene, the patient’s GCS was 3. She was breathing but stopped soon after and was then ventilated by bag-valve-mask. IV access failed and the patient was transported with bag-valve-mask ventilation. She arrived at the ED 35 minutes after being found. GCS remained 3.
Initial examination: apnoea, pupils 5mm bilaterally and unreactive with no brainstem reflexes. Pulse (radial) present, bradycardic, MAP = 54.
The patient was dead. Dead people do not have beating hearts. That was my reasoning. However brain dead people do have beating hearts. The probability of CPCR was zero. The incongruity of a beating heart led to a futile attempt at resuscitation that was continued for an additional 15 minutes.
The next dead patient who arrives with a beating heart will not have resuscitation attempted. Information that does not make sense cannot be processed under extreme stress. I know that I should disengage, but knowing and remembering under the circumstances are two different things.
Tuesday, July 24, 2007
I did a rotation in plastic surgery as a junior doctor: I wanted to have practice suturing.
During my first on-call I spent 6 hours suturing one patient: he had been assaulted with a panga. At the end of that and with more than 12 hours to go to the end of my call I felt that I had had as much practice as I could conceivably want. I still had six months of my rotation to complete.
Our commitments are made in ignorance. And hindsight is no good: given the answer all problems look solvable.
Last night I sutured a complex facial laceration on an elderly patient – it was slow, difficult suturing and took some time. It reminded me of two things: practice makes perfect (cf. practice makes permanent) and time is the ultimate value (cf. Wal-Mart vs. Google).
Sunday, July 22, 2007
Saturday, July 21, 2007
Friday, July 20, 2007
Monday, July 09, 2007
Sunday, July 08, 2007
All stress, including fatigue, narrows one’s focus. A narrow focus means failing to attend to relevant information and weighting some information too heavily. A narrow focus, then, misdirects sometimes disastrously.
Reflection improves performance and reflection in action improves it sooner. In clinical care many events are singular so that reflection after action helps only with process rather than specific actions whereas reflection in action helps with what one is dealing with specifically. Highly dynamic, time critical events do not lend themselves to reflection in action particularly because they are stressful. What is needed is the facility to step back in critical moments, to disengage.
The patient is dying; disengage. That, friend, is easier said than done.
My belief that I have no control over life and death and that death is destined allows me to disengage. I cannot save those who will die: nothing I do will make a difference. My task then is to see that those who survive do so with the best possible outcomes. There is a central inconsistency here, but inconsistency is human. And I have no wish to debate whether death is destined or not. My conviction is pragmatic: I do not decide life and death so I am free to be as heroic as I choose: I have control of the process, not the outcome.
How do you deal with stress? How do you free your stuck cognitive gears when life is on the line?
Saturday, July 07, 2007
Friday, July 06, 2007
If memory is part structure, part process and part cue and knowing is largely network both internal and external, how is social-network knowing if it is unmapped and almost all tacit? We don’t know what others know and can never know.
Needing to know, we can ask. Broadcast is most efficient, but how responsive are our networks to broadcast requests? Until such time as networks are ubiquitous and intelligent and people are responsive, broadcast will not be workable for important things.
ICT literacy is generally, lamentably, poor.