Saturday, 4 April 2015

Come April - Rules For Fools: Do they help ?


From the Desk of Sagar Galwankar, MD

I realized its April when the Social Media was buzzing with Jokes ridiculing Fools and Celebrating Happy Fools Day.

As celebrations and rediculations continued across the world needy patients continued to visit Emergency Departments and continued to be cared for as I sat wondering “When we come to Things like “Standard Orders”, “Protocols” Can we make Rules for Fools?

There is a lot of discussion that Emergency Medicine is all protocol based, its overkill of investigations, it’s all to the point, etc. etc. Additionally when it comes to Education, I come across many strategies in EM Teaching where educators want to shorten lectures and topics making the lectures “To the Point” without going into the deep logic.

Yes, Emergency Medicine is based on Fundamentals of Unknown and Vital Signs govern the paths to diagnosis and care, but I  vehemently maintain that Emergency Medicine is a science, it does have an immense content of basic medical sciences and the algorithms are based on scientific evidence with a deep understanding of the way the nature of pathology works.

Emergency Medicine evolved from a Traffic Police System of Symptom based stratification and stat disposition to different departments & physicians to its current day where one Expert called as THE EMERGENCY PHYSICIAN mans the Emergency Department with his knowledge, skills, Diligence, and intelligence. This EP makes the lives of his colleagues from all disciplines who work on the floors and wards easier thus providing Urgent Clinical Care by a Specialist to the Emergency Patient immediately on arrival to the hospital.

This transition has brought immense value to health care.

I remember the time when single handedly I started the mission to develop Emergency Medicine in India and was ridiculed by the all physicians from different specialties and hospitals.
Today the same hospitals are selling Emergency Medicine as their strong points and advertise claiming the best emergency care just to attract more patients.

Coming back to the point:

Standard Orders, Protocols and Clinical Pathways are basically a set of rules which have to mandatorily be followed. 

The creation of such templates comes after a lot of discussion, debate and consensus both at a scientific level and then at an operational level in an individual facility.
The philosophy behind such Pathways is to make sure that every patient is cared for matching the clinical evidence available. These pathways also envision ensuring that the slightest risk is negated and every patient is safely cared for.

Well the most common and the most famous clinical pathways are for Chest Pain / Acute Coronary Syndromes/ Stroke / Sepsis while the Resuscitation Pathways are standardized for Cardiac Arrest and Trauma for both adults and children. 

Clinical Protocols is a different league wherein every facility has its own Standard Set of orders to overcome the Challenge of Overcrowding and underdiagnoses / misdiagnosis of life threatening conditions. Not Missing AMI / Stroke / Sepsis or any life threatening condition, and hastening diagnosis by kick starting investigations and administering fluids, pain meds, antibiotics, antiemetics and antiallergic medications etc is the intent of such orders.

The complete spectrum of this approach is to make sure patients are cared for safely and are offered the highest quality of evidence based care.

Well the most important part of this whole story is the Physician who has to examine the patient and make the judgement whether the protocol is correct or needs to be modified in terms of medications, investigations or final disposition.

It’s not that simple and it’s wrong to assume that a protocol covers all. In a chest pain protocol the physician still has to rule out a Pneumothorax or Aortic Dissection. In sepsis the physician still has to decide the gravity and clinical condition of the patient and locate the source.

What if there is a Nausea Vomiting Protocol and the patient comes as DKA , I can remember multiple times that patient has come with nausea vomiting sugars of 1000 and his EKG shows an Acute MI but patient was being worked up on lines of Nausea and Vomiting.

I can tell you multiple incidents when patient came with symptoms saying that they had facial weakness and hemiplegia which resolved and was started on TIA protocol and I walk in and do a stroke scale and find the patient to have visual deficits and then change it to Stroke Alert Stat CT and TPA. Not every TIA goes for Stat CT with radiologist read in 10 minutes.

The point I am making is that Doctors are the ones whose knowledge will help the protocols to function optimality. 

Protocols have their downside too.

Developing protocols is cumbersome and time consuming and involves multiple departments, individual specialty guidelines, and operational rules and by-laws of the hospitals. There are times when the protocols finally see the light of the day and scientific evidence changes and again the protocols have to be modified.

These standardized rules have a downside at academic emergency departments. Post Graduate Students tend to just implement protocols without knowing each and every step in the protocol. They need to learn and understand the logic.

I am cautious to support these new era of “Short to the Point Lecture Format” which is immensely misleading and disastrous if one does not know the logic behind every point.

That is the very reason Boards in Emergency Medicine across the  world have a written as well as an oral component and only a handful of specialties in have both exams with majority only conducting and certifying based on MCQ Written Tests.

Emergency Medicine is a branch of Challenge and Opportunity.  

Emergency Physicians will never have patients to be followed as Primary Physician, They may not be great surgeons but they are surely doctors whose difference is visible and that too immediately.
The actions we take and the reactions to the actions is what saves the patients or doesn’t.

With responsibilities of MAKE OR BREAK on our shoulders, surrounded by an Era of Accountability to self and your patients and trenched in systems with egos, protocols, patient safety and quality, having the up to date knowledge becomes more crucial than ever.

On the other hand Teaching correct knowledge and practicing as per current algorithms is very important in our specialty.

We may have the best tools, we may have the most up to date rules but in hands of a fool there is no value to any tool or any rule because a fool is a fool regardless…..

Solution is .......cure the foolishness…read, learn, practice and improvise with a deep understanding of the scientific subject matter. 

We are dealing with lives and not some product manufacturing industry!

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