The value of monitoring and making sense of your critically ill - TopicsExpress

The value of monitoring and making sense of your critically ill patients. How do experienced clinicians see beyond the superficial and understand the trouble brewing behind the scenes, seemingly before there is any warning? Where does such an unearthly prescience of what is about to happen come from? How is it that one sees what another doesn’t? When we make sense of a clinical situation we are noticing cues or changes in a patients condition. We take this information and interpret it to create a plausible story (or stories) and then we act — and the results of our actions serve as a test of the plausibility of the story. The better we are at sense-making the more subtle the cues and changes that we notice, the more plausible the stories that we create, the faster we act, and the more closely we monitor the results. The difference between the novice and expert sense-maker is perhaps exemplified best in anaesthestics, where experienced anaesthestists are quicker to detect changes in the patient’s physiological status, and quicker to act. Noticing the cues is perhaps the most important step, and it is usually simply a matter of being surprised. This occurs when something unexpected happens. This implies that we had expectations of what was going to happen in the first place! - Deal with problems not diagnoses Recognise that conditions constantly evolve in emergency situations and that we are prone to premature closure and confirmation bias. Diagnoses are always much easier in hindsight. - Learn to make explicit expectations so that violations are easier to spot. Predict what should be found on examination and on investigations if the working diagnosis is correct, and force yourself to re-examine your interpretation if these findings are absent. - Develop the habit of stepping back to assess what is happening. Periodically review cases and search for information that doesn’t fit. - Learn about situation awareness, how to become attuned to your environment and how to detect and correct errors. - Beware of ‘labels’ Labels are useful for interpreting cues but if too specific may lead to to entrapment bias. The importance of diagnosis is over-rated – undifferentiated RLQ pain is often a more useful label to work with than probable appendicitis or probable ovarian torsion. Keep labels broad, at least early in the diagnostic process. - Appoint a Devil’s Advocate This is often the role of the attending/ ED consultant, but if you’re alone it will have to be you! The Devil’s Advocate should ask questions like: “What else could be going on? Why do you think that? Have you considered this? What if this happened?” - Seek a variety of interpretations How does the physiotherapist, pharmacist, or nurse view what is happening? Different viewpoints give you more information to work with and help guard against confirmation bias.