A Healthy Dose of Fallibilism

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A Healthy Dose of Fallibilism
“Reason itself is fallible, and this fallibility must find a place in our logic.” - Nicola Abbagnano

Decision making in Emergency Medicine is intensely complex and it also the defining characteristic of the practice of Emergency Medicine.  To outside eyes we may seem to be a specialty of action: chest tubes, intubations, heroic resuscitations with massive amounts of blood products and IV infusions.  In truth none of the “action” of our specialty, the big sexy things they make into TV shows and movies, occurs without rapid, precise, and accurate thinking and decision making.  But the Emergency Department can be a hostile environment to the decision making process.   And, I’m not just talking about the noisy environment, the multiple interruptions, the patients with a wide variety of chief complaints and acuity seen in quick succession.  There’s seemingly a thousand different hurdles between the instant a patient recognizes that something might be wrong with them and the moment a clinician diagnoses the problem. 

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Grand Rounds Recap March 30, 2016

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Grand Rounds Recap March 30, 2016

M&M with Dr. LaFollette

Modified Sgarbossa Criteria to aid in diagnosing STEMI in the setting of LBBB

  • Can be used in the setting of induced (paced) LBBB
  • Unweighted scoring (any of the following indicates STEMI equivilance)
    • Concordant ST elevation
    • Concordant ST depression in V1,V2,V3
    • Inappropriate discordance of >25% ST elevation / S wave amplitudes
  • Improves your test metrics from the original criteria from sens/spec of 36%/96% to 80%/99% respectively in a new validation study

 

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Grand Rounds Recap 2/3/16

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Grand Rounds Recap 2/3/16

This week we had our annual Critical Care Symposium where we invited our own critical care trained faculty and a special guest to have a day chock full of critical care goodness.

Refractory septic shock with Dr. David norton

Dr. David Norton, Assistant Professor of Medicine and Director of the UCMC Medical Intensive Care Unit

Definition of Refractory Shock:

No clear definition exists, but we are generally describing a state of decreased vascular responsiveness despite high vasopressor infusion.

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The Little Things that Matter

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The Little Things that Matter

We were fortunate, a couple weeks back, to have Dr. Brian Burns of Sydney HEMS come and speak to us.  In his lecture, “When the 1% Makes All the Difference” which you can find here, Dr. Burns hit on a number of excellent points.  We sat down and talked with Dr. Burns a bit more extensively over a couple of the themes of his lecture.

In this podcast, we cover some of the plus/minuses of checklists, the importance of high fidelity continuous training practices (simulation, routine case debriefing, intensive induction training), and the role of cognitive factors in running resuscitations.

Should resuscitations run like a jazz quartet or a Formula 1 pit crew?  Are checklists simply in the way or do they cognitively unload the team members to improve performance?  How do you train cognitive factors in resuscitation?

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The Myth of the Stable STEMI Transfer

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The Myth of the Stable STEMI Transfer

We fly/transfer many patients with STEMI on Air Care and Mobile Care.  And, fortunately, a majority of these patients end up doing very well.  You accept them at the referring facility, load them in the helicopter, and transfer them to the cath lab at the receiving facility without incident.  You certainly may make some adjustments in nitro drips, maybe give some metoprolol, certainly review their outside hospital records, but usually the biggest benefit you are offering them is rapidity of transport.  Transport 20 or 30 of these patients without incident and you might get lulled into thinking that these patients are so incredibly stable that nothing bad will happen during the course of the transport.  To do so would be folly.

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