Dr. Gawande--ICU checklistsLa

[medicdan]

In Last week's New Yorker , Atul Gawande had an essay on ICU medicine and its complexities. Below is an excerpt, and I am including a link. It may seem like a long article, but I think it has big implications for EMS.

On any given day in the United States, some ninety thousand people are in intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an I.C.U. from the inside. Wide swaths of medicine now depend on the lifesupport systems that I.C.U.s provide: care for premature infants; victims of trauma, strokes, and heart attacks; patients who have had surgery on their brain, heart, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, I.C.U.s barely existed. Today, in my hospital, a hundred and fifty-five of our almost seven hundred patients are, as I write this, in intensive care. The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six per cent. Going into an I.C.U., being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande
I dont know how long the link will be active.

What are your thoughts on "checklist medicine"-- how does it compare to our "cookbook" medicine? Do checklists have a place on an ambulance? I'm interested in BLS and ALS points of view on this.

What do you think?

 

[medicdan]

^Bump^
c'mon, I know someone has to have someting to say about this.
I understand it has been put up in ERs and CCUs all over, and there has been much discussion over the article on other forums.

 

[Ridryder911]

Definitely a long article that describes physicians in some areas have not a clue on educational medical systems. Check lists ( as described by the article) have been in affect for decades in other allied health areas.

Even in EMS we have primary and secondary assessments, to even include checking for the scene is safe or not. Again, nothing new except for the MDiety. If one was to follow grand rounds and rotations, one would be appalled at the way they are taught.... "see one, do one, teach one".. no joking. In EMS, nursing, and most other supportive staff, check list maybe in the form of tree protocols, check lists with action, skill, intervention, reason, and results for evaluate.

The difference in cookbook medicine and check list the ability to expand and make a hypothesis. With the understanding that practicing medicine is more an art than just science. There are so many variables and multi systems a "simple checklist" is impossible and could be dangerous. That is why it is so essential to diverse in education and exposure of multiple.

I do agree with the author more structure should be taught at the physician level. Again, as the article points out there are many times things are missed because of confusion. For example multiple specialist that cannot see the for rest, nor the trees only the leaves that they have specialized in. Unfortunately, there is usually no collaborative plan or gathering to plan the treatment modality. Everyone is on their own.. and the patient suffers. Yet again, many times this is associated with the attitude that is formed and promoted in medical schools.

We in EMS already have check lists, unfortunately too many. Memorization is promoted without the knowledge behind the rationale and the intervention if there is an altered answer. Thus the reason and need for further in-depth education.

R/r 911

 

[VentMedic]

Checklists can be general and precise taken many times from P&Ps written for a procedure. When preventing a particular problem such as VAP (Ventilator Associated PNA), a checklist to encompass all possible areas that can create a problem are covered. From that checklist, other checklists and P&P spin off. Every system and potential problem has to have an action to accompany any possible signs of trouble.
When intubating, inserting an Arterial line or IV, another checklist can be made from the P&P for each procedure. However, when nurses and allied health personnel do these procedures and not a doctor, the lists are usually brought out only for QA or monitoring puposes.

All the physcians at the good hospitals have probably been trained or at sometime been made aware of the correct way things need to be done. But, since no one really monitors them like RNs and allied health workers monitor each other, they deviate from the acceptable standards.

Thus, infections occur, pts get sicker and may die from even the slightest break in protocol.

There were several studies done in the 80s and 90s that proved CRNAs and RRTs could intubate and put in arterial lines with very minimal infection rates as compared to physcians.

Deviating from the standard procedure for what is known to be acceptable quality can go for any system including EMS that does not have the appropriate monitors in place to check skill, technique and knowledge.

I was lucky that my IV skills were taught 30 years ago by a serious RN back when RNs still taught many of the paramedic classes. I learned good technique and was given a reason for every step I did. That stuck with me.

My intubation skills were excellent in the field after 10 years but were not up to a hospital standard according to any check list that the RT department produced. I had to be retrained. Thus, I learned to appreciate good technique to benefit the patient for the long haul and not just NOW. Luckily, the things I've learned in the hospital are second nature to me and easily follow me to any transport vehicle. If you want to see checklists if only in the minds of the team members, follow an advanced Neonatal Transport Team around.

The "it's an emergency" stuff doesn't fly when it may only take an extra 10 seconds to prevent further complications.

Now, in our ED, if a paramedic student wants to start IVs, they will abide by our "checklist". There will be no "but I'm going to be a Paramedic and we don't have to do it like that" when working on a patient inside our walls that depends on us to keep them from health care induced harm.