The Importance of a Solid Foundation

Here is another guest post by my colleague James. This is an excellent piece on the importance of approaching scenarios in a cohesive, standardised manner that still allows some flexibility. Emergency medicine is actually based on some pretty simple concepts as James discusses.

As an ALS clinical instructor who also dabbles in teaching at university, the one single concept I harangue all my students with is the idea of having a good clinical approach. Teaching many students in one form or another has shown me that this is the single most useful thing that anyone can learn in paramedicine. Unfortunately it’s one of the most unevenly applied and its importance is poorly understood. So today I want to try to get across why it’s critical that the student paramedic gets this straight in their head.


Imagine you’re a qualified paramedic and you’re working with a more junior partner. You’ve only recently achieved your qualification and you’re keen but aware that your approach is a bit slipshod. It hasn’t been a problem thus far because you’ve always managed to wing it until someone else arrives or hide behind the experience of a more senior partner.

Today however you’ve been dispatched to “the Big One”. It doesn’t matter what it is, a sick multi-trauma, an APO with no blood pressure or a multi-casualty scene with body parts all over the place. You instantly recognise that it’s serious and that you’re in well over your head. Your mind has gone blank. All the knowledge that you thought you had stored away has evaporated and you’re left holding the blood pressure cuff. You don’t know what to do. You don’t know where to start. Maybe the patient sickens and dies, maybe they don’t, but you have failed them in their time of need due to your inaction in the face of a complex scene.

Not good, I think you’ll agree.

Imagine instead the same situation, but this time you’ve worked hard with your Clinical Instructors to nail down a really solid clinical approach. You haven’t seen everything yet, but you’re sure you’ll be able to handle it because you have a system. When you arrive at the case you’re petrified… but you get to work anyway. You approach this patient the same way you approach every other patient – primary survey, key history, vital signs, secondary survey, management, transport. Even though your heart is in your throat and you feel like you’re about to freak out, your clinical approach is so well ingrained into your mind that the job seems to virtually run itself. The patient gets better and you get a pat on the back. Well done.

That is the difference between a good clinical approach and a poor one.

A great deal of research has been done showing that people only have a limited ability to make effective decisions. If certain behaviours such as what to eat for breakfast or when to go to the gym are automated, they are far more likely to happen and the person feels better about it. Another thread of research has shown that repeated, deliberate, error-focused practice results in superior performance and effortless repetition later. Practice makes permanent.

The upshot of this research for paramedics is that if you practice your clinical approach while you are studying, by the time you are qualified and independent it will be second nature. Every patient will receive the same thorough assessment, and you’ll have a cognitive surplus ready for when the Big One happens and you have to make a lot of decisions. You have to deliberately create this cognitive surplus, it won’t happen on its own and you can’t rely on adrenaline.

The heart of a good clinical approach is a series of mental checklists. If you look at superior paramedics like Ben Meadley (@prehospitalpro) you will see that all his gear on the helicopter is labeled and checklisted. It takes the thinking out of the process and reduces errors. For the road-based ALS clinician, you should be working through some kind of consistent assessment process. I mentioned mine above, but here it is again:

Primary Survey -> Key Hx -> VSS -> Secondary Survey
Diagnosis. Plan.
Rx. Transport.
Reassess.

That’s it. Simple, but deceptively powerful. My approach doesn’t have to be exactly the same as yours, but yours needs to be consistent and tick off all the key points.

A good clinical approach will save you every time. The very sick patient, the logistical challenge patient, the everything’s-broken-and-I-don’t-know-what-to-do patient – all of them will be manageable with a good clinical approach. But all of them will be horrendous without it. You owe it to yourself, to your patients and to your clinical instructor to make it your priority

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3 Responses to The Importance of a Solid Foundation

  1. rfdsdoc says:

    Reblogged this on PHARM.

  2. Scott Sartor says:

    According to the ‘Advanced Assessment and Treatment of Trauma Course’, the most important skill that we perform is the skill of assessment. I recently enjoyed the following podcast on the PHARM: http://prehospitalmed.com/2013/09/10/pharm-podcast-80-get-my-coat-with-dr-nicholas-chrimes-professor-michael-buist/ , which emphasised rapid assessment, treatment of life threats (eg, ABCD), then further assessment and potential tx of ‘working Dx’. If practice and repetition breeds behaviour than we need to enter each scenario with a standardised approach… I’ve replaced the ‘Paediatric Assessment Triangle (PAT)’ with the ‘Patient Assessment Traingle (PtAT)’ which is also a formal ‘look test’ process. I also encourage my colleagues to use both subjective data as well as objective data in those first 5 minutes. The 1st pass of the PtAT follows the PAT subjective findings from the doorway of the pt’s appearance, breathing, and circulation. The 2nd pass uses objective findings: in the corner of the triangle between appearance and breathing, I assess SPO2; between breathing and circulation, I assess ETCO2, and between circulation and appearance, I assess CBG and BP.
    Keep up the great work…. From Canada… Scott

  3. Pingback: Surviving your first year on road part 3: Miscellany | AmboFOAM

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