Mission: Healing December 26, 2011

PGY 39, Day 178

The Christmas Holiday Vortex was pulling hard this past week, but despite that and the skeleton crew, we were able to stay on TARGET and on task in the ICU. Patients and families were well cared for, and they always appreciate the good care. How can we do it? Focus on the mission ... mission integrity and mission adhesion, facilitated by our team development tools. The message to the team is simple, Sick Patients Take no holidays and there is no room to cut corners on the Critical Care Mission ... EVER ... not for one second of any day ... NEVER cut corners on patient care or patient safety!

A message for PATIENTS & FAMILIES and INEXPERIENCED CARE GIVERS ... before I get into the meat of our work discussion ...

Please, I beg PATIENTS and FAMILIES to make sure their wishes are known, because this work is very intense ... and it requires our dedication to PRESERVATION of LIFE and limb. It is shameful to waste resources on people who do not want us to do our best to fix what we can fix. If you don't want critical care ... PLEASE don't let yourself, get to the ICU. Make sure your family knows you DON'T WANT the hospital and especially ICU care. There is nothing worse from THIS experienced intensivist's point of view than to have families start to waffle on a care plan before a proper therapeutic trial has been carried out. Advanced directives are useful, but they are rare, and they are VERY RARELY SPECIFIC. IF in our best judgment we are carrying out the patient's wishes, let us carry on until we are sure ... absolutely certain that we are doing what is in accordance with our Critical Care Mission. Please don't undermine our mission.
And ... as for inexperienced care givers ... plaese stay out of it. In other words, please leave these decisions to the EXPERIENCED MEMBERS OF THE TEAM. Let the Experienced Providers determine what is a proper trial of care. If you don't know what you are doing, do nothing and get help. If you don't know what you are talking about, say nothing and get help.

This is a reiteration of my big picture teaching this week.

What is the Critical Care Mission?

Preservation of Life, Limb, Organ and Vital Human Functions in accordance with the wishes of the patient, and with the intent to serve the best interest of the patient at all times.

In that context, and in the context of the family, the Intensivist and his team of care givers, must include the family in the team, and should relentlessly strive to achieve the following Goals and Objectives as soon as is possible:

A. GOALS: NOW = UPON ARRIVAL

SIMULTANEOUS and RAPID (within seconds to minutes)

-Resuscitation,

-Preservation and Restoration of

-Perfusion, Oxygenation and Ventilation to

-Optimize preservation of Life, Limb and Organ function

-Recognize and treat coexisting diseases, precipitating illnesses and/or injuries

B. OBJECTIVES:

SIMULTANEOUS and RAPID (within seconds to minutes) EVALUATION & TREATMENT to

1. Optimize cardiac output and end organ perfusion

2. Oxygenate the blood

3. Remove carbon dioxide from the blood

4. Deliver oxygen to Tissues, Organs/cells

5. Remove carbon dioxide, metabolites and toxins from Tissues, Organs/Cells

(organ priorites are a. Heart, Brain/CNS, Lung b. Kidneys c. All others)

6. Diagnose and Treat the Precipitating Illness/Injury

7. Restore Vital Functions and Optimal Physiology (total organism) ASAP (within minutes to hours) to Prevent and Limit Limb and Organ Damage As Much as is possible and as rapidly as possible (minutes to hours)

8. Prevent complications of Illness, Injury and Treatment as much as is possible (from start to finish)

9. Promote optimal recovery and restoration of normal function through rapid mobilization and rehabilitation as soon as is possible.

10. Restore patient to normal, productive and creative life, as much as is possible (To srart As soon as is possible ... and to continue as long as is necessary for days to weeks to months to years), and to help the family throughout this process.

Toward these ends, we have developed a comprehensive set of check lists designed to help facilitate team care of the sickest patients in the care of teams with varying levels of knowledge, skill and experience. Our Check Lists, all part of the StepWisely(R) System include STOMPP(TM) & STOMPPIT(TM) The Strategic Targeted Operations Management for Patient Protection Integration Tools to promote Optimal Patient Care Through Teamwork. This

Comprehensive checklists includes:

TARGETS and GUIDELINES to Promote

1. Family Integrity, Participation, and Protection - FIPPs(TM)
2. Patient Integrity Protection & Preservation - PIPPs(TM)
3. Patient Organ Specific Protection & Preservation Guidelines POPPs(TM)
4. Targets for Organ Specific Protection, Preservation & Treatment Strategies (Generic and Disease Specific) - TOPPs(TM)
5. General for ALL Pateints Prophylaxis - GAPPs(TM)

I have been using these check lists to help keep the care teams on Target for the last few years. The less experienced find them particularly helpful in light of the many distractions that are rampant and increasingly complex. Focus on the patient and on patient safety. When in doubt go see the patient ... don't rely on the record, or the documentation for decision making, but rely on reevaluation of the patient. The less stable the patient, the more time you should spend at the patient's bedside.

If you have questions, or want more details, respond to this blog, or email me @ Dr.Mike@ihealsolutions.com and I will get back to you as soon as I can.

Buona Fortuna!
Enjoy!
Dr. Mike

Mission: Healing December 20, 2011

PGY 39, Day # 172

ICU Rounds details will follow as the week emerges. A few thoughts will have to suffice for now.

Perfusion is the MASTER of Critical Care ... the MASTER of organ preservation, protection and resuscitation ... the MASTER of healing.

STOP THE MADNESS(TM) Rational Cost Containment
StepWisely(R)
STOMPP(TM) & STOMPPPIT(TM) tools to promote mission adhesion, team development and optimal patient care.

More on the blog as soon as I can get to it.

Think about it and have a great day!

Dr. Mike

Mission: Healing December 12, 2011

PGY 39, Day 164

Ask the survivor?

It has been know for decades that patients can't survive after traumatic cardiac arrest "in the field" despite the best of care. In other words, if you have an accident or significant injury from any cause, if it is severe enough to cause your heart to stop, and to require cardiopulmonary resuscitation, you are probably dead. And, then there are the exceptions ... the occasional patient who survives, despite the fact that they "should have been dead."

Recently, an article published in one of our medical journals looked at the cost and outcome of treating patients who "should die" as a result of their trauma.

http://www.ncbi.nlm.nih.gov/m/pubmed/21986740/

According to this study, which involved the authors examination of trauma patients' CHARTS retrospectively (after the care was given), of the 294 trauma patients who should have died, only one survived despite treatment (0.3%) and required "long term care". The TOTAL cost of treating these patients was stated to be $3,852,446.65, or $13,103.50 per patient. They considered treatment of these patients to be a "violation" of guidelines and conclude that "no loss of neurologically intact survivors would have resulted had strict adherence to the guidelines been maintained."

Wow ... pretty harsh and rigid conclusions, but are they correct? Not so fast!

Here are my recommendations:

1. Ask the survivor! What is his or her current status?
2. Examine all trauma registries with regard to similar data?
3. Examine all survivors who "should have died" and see how they differ from the group at large?
4. Do a prospective randomized trial?
5. Examine the details of each case identified in the study and determine weather or not any of the care provided could have been improved?
6. What else? I always forget something. Please comment

Medical care should not be wasted on dead patients, but it is precision early care that dictates survival. How many patients were saved and are doing well, because VERY AGGRESSIVE CARE was provided in the field? Scoop and run is probably the best once an airway is established. Despite this "study" my opinion stands: When in doubt, err on the side of life & when you are dead, you are dead. So ... the problem remains ... how to determine death ... and especially how to determine who of the critically injured will die despite the best of care? In the meantime ... until we can answer these questions properly, err on the side of life, so people who have the potential to survive and live a good life don't die unnecessarily.

StepWisely(R) and have a nice day!

Dr. Mike

Mission: Healing December 5, 2011

PGY # 39, Day 157

During my Family Medicine years, I noticed that a small percentage of the population (5-10%) is HIGHLY motivated to TAKE CHARGE OF THEIR PERSONAL and FAMILY HEALTH & WELL BEING. The Stress Management Workbook was written for these people in 1981 and originally published by Appleton Century Crofts. Since then, many have copied our work (some plagerism, I am sure), but none have made it better. NOW, you can get The ORIGINAL Stress Management Workbook by Aronson and Mascia in electronic format through Kindle books @ Amazon.com for less than half the original purchase price. This is very exciting to me ... to think that this book is now readily available to a world wide audience ... is truly phenomenal.

http://www.amazon.com/The-STRESS-Management-Workbook-ebook/dp/B006BIR5TO/ref=sr_1_2?ie=UTF8&qid=1323101547&sr=8-2

Also, I am happy to announce that David, at Voltage Design

http://voltagenj.com/

is helping to set up chats for those who buy the book. Wow, the wonders of modern technology! To think that you can get this book and support for use anywhere in the world is truly amazing.

If you have questions about the book, or any of my blog posts, feel free to contact me through this blog, or by email @ Dr.Mike@ihealsolutions.com.

Have fun and be careful.

Ciao for now and have a great day.

Dr. Mike