We are going to start posting questions or statements to start a significant discussion group.
Our goals are to :
- Start a wide berth of discussions.
- establish synergies of thought.
- improve patient care.
- improve interdisciplinary communications.
- introduce varied approaches to healthcare.
- decrease length of intubation.
- decrease length of time to liberation from mechanical ventilation.
- decrease length of hospital stay.
- decrease the cost of health care.
- introduce new or variant concepts of ICU care.
Here is the first 2 of many thought provoking statements.
Evoking Epipheny – 2019-05-001
You are called for a patient who is agitated & having a desaturative event > you see the following as you enter the room :
The Intensivist meets you at the patient bedside to discuss the patient. His SBAR report :
S – Situation : Patient agitated & demonstrating oxymetric desaturation to 69%.
B – Background : Cardiogenic shock > Post-op day #3 ; Hospital day #4.
A – Assessment : Patient agitated but looks comfortable.
P – Plan : Increase FiO2 from 35% to 50%.
Do you concur?
The patient was on the following ventilator parameters in the CTICU : SIMV-VCV, RR(set)=8, Vt(set)=700, FiO2=50%, PEEP=5.
The patient will be in the MRI suite for the next 75 minutes.
a) what will the settings be on this ventilator ?
b) how do you set patient trigger ?
c) how do you set Vt(set) on this ventilator (the “cheat sheet” was ripped off of the side of this ventilator).
d) if you use the vent with the settings that are currently dialed in, what will the ventilators translate to in standard ventilator parameters.
In a nutshell :
SBAR – quick / rapid report handoff format adopted by hospitals.
why the submarine pic ? SBAR format was initially designed by submarine personnel.
The long winded version :
(in a submarine : deep, deep underwater with limited oxygen supply and tons of crushing pressure all around, there is not time for lengthy speeches – its more like “you have 2 seconds to tell me what’s wrong and how you would fix it”.
I was told a long time ago, by my supervisor back then, “don’t come to me with just a problem … have a suggested solution as well”. I have always liked that management style and give her credit for introducing me to that notion.
The third point, always know the history of anything and everything (in this case : SBAR came from the military).
We should treat a patient in crisis just like we were having a crisis in a submarine :
tell me the problem.
give me relevant background quickly.
tell me why you think the problem happened.
tell me how you would fix it.