Over the years we’ve been building up a profile of our virtual hospital, St. Emlyn’s. Here, let’s explore the way we reflect on cases in Emergency Medicine, and take a look at what might go on at a ‘St. Emlyn’s Case Conference’, something that a lot of EDs are doing nowadays to encourage reflection, and perhaps something we could consider implementing at our own (real life) EDs. The following is an entirely hypothetical case from Virchester, which is based on genuine cases and observations from my practice over the years.
A 30 year old asthmatic woman is brought to St. Emlyn’s ED with shortness of breath. She has a past history of asthma, but has never had anything more than a moderate exacerbation. This occasion appears to be similar. The peak expiratory flow rate is at 60% of her best and there are no signs of life-threatening or severe asthma.
[DDET Signs of severe and life-threatening asthma]
Signs of severe asthma
- PEFR 33-50% of best or predicted
- Respiratory rate ≥25/min
- Heart rate ≥110/min
- Inability to complete sentences in one breath
Signs of life-threatening asthma
- PEFR <33% of best or predicted
- SpO2 <92%
- PaO2 <8kPa
- Normal PaCO2 (4.6-6.0kPa)
- Silent chest
- Poor respiratory effort
- Exhaustion, altered conscious level
The patient is treated with nebulised salbutamol and oral prednisolone and the PEFR rises to 70% of best. A couple of hours later, the patient is looking and feeling a lot better and admission is arranged for a period of observation. Prior to leaving the ED, her condition suddenly deteriorates. On arrival in the Resuscitation Room she is deeply cyanotic with gasping respirations, undetectable oxygen saturation, a heart rate of 160/min and a blood pressure of 90/40. The chest is near silent with a tight expiratory wheeze. There is no response to further nebulised salbutamol. An ECG shows sinus tachycardia.
IV access is secured and the patient given high flow oxygen. Thoracic ultrasound demonstrates no pneumothorax. An arterial blood gas demonstrates a pO2 of 3kPa in oxygen and a pCO2 of 15kPa. The patient is agitated and continually removes the oxygen mask, precluding successful pre-oxygenation. A delayed sequence intubation is therefore undertaken with a pre-med of 50mg IV ketamine. This enables satisfactory pre-oxygenation with the use of a Water’s circuit to a saturation of 87%, at which stage the patient is anaesthetised with a further push of IV ketamine and suxamethonium. The trachea is intubated immediately with transient desaturation to 80%. After re-oxygenation, the ventilator is disconnected to allow manual decompression and reduce gas trapping. Subsequent ventilation at low tidal volume and respiratory rate with permissive hypercapnia enables re-oxygenation to 95% and a return to normotension. IV salbutamol, magnesium and hydrocortisone are administered, sedation is maintained with inhaled halothane and the patient’s condition stabilised prior to transfer to the ICU. Another life saved!
Virtual reflections at St. Emlyn’s
This would be a great case for discussion at a Case Conference. Case Conferences are designed to help us to reflect on challenging cases and to identify areas where we might improve our practice for the future, including both the resources that are available and the way we use them. In reality, I can’t say that I’ve had the opportunity to regularly attend Case Conferences, although I have arranged for team de-briefs and I can see the potential value in making Case Conferences a regular feature of our ED in real life. Do you regularly hold Case Conferences at your ED? If so, we’d love to hear from you and learn from your experiences.
What might we discuss?
There are, of course, a million things to discuss around this particular virtual case. In this blog post, I want to explore the way we reflect on cases in medicine, and to highlight what I think would be the most likely topic of discussion when we reflect on cases like this in our current climate. What do you think is most likely to be discussed at a St. Emlyn’s Case Conference? Would it be the heroic salvage of a peri-mortem patient by an over-stretched and undervalued team? Personally, I don’t think so. Would it be the implementation of cutting edge techniques like DSI and thoracic ultrasound to ensure that this critically ill patient stood the best chance of survival? I’d suggest probably not.
Perhaps I’m wrong but, from my experiences, I actually wonder whether we might, instead, be inclined to attack the doctor who managed the patient prior to the deterioration. How did they fail to recognise the seriousness of the situation? Surely they failed to spot some important clinical signs and missed an opportunity? Did they not realise that a deterioration of this nature was bound to happen?! In my experiences over the years (and not necessarily in my current position), this is actually even more likely to happen when the doctors themselves are absent, thus giving them no chance to respond.
Now, I do value opportunities to reflect very highly. Among other things, that’s what makes a good Resuscitationist, as wisely pointed out by Scott Weingart and Cliff Reid in a recent podcast. And there would quite clearly be learning points to take away from a case like this. However, I personally wonder whether we could take an even better approach to reflecting on cases at events like Case Conferences.
Do we, and should we, have a ‘no blame’ culture?
“To avoid criticism say nothing, do nothing, be nothing”.
I think we’re often quick to criticise and slow to praise in medicine. There’s a professional pride involved in ensuring that our patients have the best outcomes. Those who fail to achieve the best outcome for any given patient must clearly have done something very wrong, and it’s our job (as physicians with superior judgement) to point out their faults.
“How much easier it is to be critical than to be correct”
“Don’t criticize them; they are just what we would be under similar circumstances”
It’s extremely easy to criticise, but we should realise that some adverse events are entirely unpredictable in medicine, which is, after all, a “science of uncertainty and an art of probability” (William Osler). As Cliff Reid put it in his excellent Resus.me podcast, we all have skeletons in our medical closets. Perhaps “he who is without sin should cast the first stone” (Jesus Christ). When we do criticise, we should recognise that there are ways and means of doing it properly. “Praise in public, criticise in private” (Vince Lombardi) is a useful principle to remember. Of course, we do need to learn from other peoples’ mistakes. But, in my opinion, they should be offered the opportunity to share the learning themselves, and any constructive feedback is best given, at least initially, in private. Most doctors reflect deeply on cases that might have gone better – I most certainly do (often at the expense of sleep!). When, on reflection, a doctor realises their shortcomings and is committed to overcoming them, criticism is unlikely to be productive. In the case of overt incompetence, it may unfortunately be necessary. But, wherever possible, helping the doctor develop a plan to overcome their shortcomings and to improve the care they can provide in future is preferable by a country mile.
The value of praise
“Praise 10 times more than you criticise”
Greg Henry, ICEM 2012
We’ve already touched on this in a previous post by Simon Carley but this is a key point to be emphasised. In medicine (and probably life in general), we tend to be very, very bad at dishing out praise. As a Consultant in Emergency Medicine, it sometimes seems as if I handle 10 complaints and 10 critical incident reports for every thank you note that comes through! In giving feedback to colleagues, we might actually run at that sort of ratio. If St. Emlyn’s were to run a Case Conference for the case described above, I wouldn’t be surprised if the key theme of the discussion was around their management prior to deterioration, as that’s the area we can quite easily criticise. It’s much harder to pass comment on the salvage of a peri-mortem patient. Can you remember the last Mortality & Morbidity Meeting, Grand Round, Case Conference, or even an informal discussion between colleagues where notable practice was commended? I would guess that it’s far easier for you to remember similar meetings or discussions where care was criticised.
The bottom line
In reading this blog post, I want you to take a few key points away. First, I hope you found the case (although a hypothetical one) educational. Acute asthma can be unpredictable and difficult to manage, and cases like the one presented are unfortunately quite common. I’ve found principles like the DSI extremely helpful in my practice, and I would honestly suggest that it has helped me to save real (not just virtual!) lives. Just make sure you know what you’re doing before you try it.
Second, I hope that you, like me, will always value opportunities to reflect on your practice and to learn from the practice of others. These are the foundations of medicine, and the means by which we improve the care we provide. Remember to use the likes of Case Conferences, M&M meetings, team debriefs and Grand Rounds as an opportunity to praise others and celebrate the things that have gone well. Never make the shortcomings of others your focus, and set out to learn at least as much from what others do well as you do from their mistakes. ‘Critical Care’ should not be taken literally!
“It is more difficult to praise rightly than to blame”
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