For the past six weeks I have been transitioning to life on the Caribbean island of Barbados. A little over 2200 miles from my hometown but I am really enjoying the 80-degree daily weather of the Barbados Winter instead of shoveling snow this time of year. Barbados is home to the world’s oldest commercial rum distillery, and I have definitely taken a liking to the local rum punch. Each bar makes a different recipe, no two have been the same, but they all come out tasting amazing. I am on the search for the perfect recipe and have been combining the advice of the local bartenders but have not been able to perfect my product just yet.
So, you’ve read this far and you’re probably wondering... what does my taste for rum punch have to do with medicine, FOAMed, or critical care?
A lot actually.
Just as No Two Rum Punches Are the Same, Neither Are Patients
You have two septic patients, both from the same infection source, both reasonably in the same general state of health, and their infections are presumably from the same infection source. They will of course develop the same clinical course and should be treated the same way, right?
If you have spent 5 minutes in medicine and treated more than one patient, you know that is not the case. Each patient we encounter in clinical practice requires a different recipe. Whether it is their underlying disease that is contributing to their acute complaint, or just a bit different physiology than the last patient you saw with the same illness, they require something different. They require care that is tailored to them.
EMS tends to be very protocolized and algorithmic, sometimes that is a good thing especially when evidence-based treatment guidelines are effectively utilized. But a one size fits all approach to handling a specific complaint or illness is not ultimately what is best for our patients.
What it takes to provide excellent care for the patients we encounter is being able to distill our vast amount of knowledge and experience into the right recipe, or the right treatment plan that is tailored to the individual patient we have in front of us. This is an incredibly high-level skill.
If we take a look at Bloom’s taxonomy, most of us can remember what we learned in a class, understand an article, and analyze a research study. In medicine we have to go further than that. We have to create. We have to combine the vast amount of information available to us into the right thing for a patient.
A Little Bit of This, A Little Bit of That
Imagine you have a formulary of every drug you could possibly want, cost wasn’t an issue, and you had the freedom to practice what you consider to be perfect medicine. You’re presented with a patient with hypotension and bradycardia and you have no immediate cause.
What’s your first course of action? Do you start transcutaneous pacing? Do you hang a vasopressor? What vasopressor should you choose? Or do you do both of these things?
There is not always one correct answer here. If you ask 10 different experts in the field, you may receive 20 different answers for how to approach the initial management of that patient. There are algorithmic approaches that are often the one size fits none model, but your job as a clinician is to treat the patient in front of you and as we established above... no two patients are exactly the same.
The mix of interventions you choose to perform will ultimately impact the outcome your patient has and influence their continuing care once you initiate it. The power to make effective treatment decisions in your role as a clinician has the power to impact the remaining life your patient has. That is an incredible responsibility.
What shapes the decisions we make in deciding what interventions our patients should get/what ingredients we add to the mix?
One may argue that everything we do should be evidence-based, but sometimes our patients require a personalized treatment plan beyond what the sources we have available tell us. Our ability to be good clinicians is shaped by a number of factors including our initial education, our experiences, best practices, our mentors, and our biases.
Outcomes Are What Matters, A Recipe for Success
Some things really come down to principles vs. preferences and that applies across the spectrum of emergency care and critical care provided by EMS providers. Let’s go back to basic EMT training for a second. When you learned to splint an extremity, what was ultimately important? That you immobilized the joint above and below the injury, that you secured the entire extremity, and that the hand/foot was in the position of function at the end. As long as you adhered to those principles, there were many different options or preferences you could have for how you got the job done.
Many of you have now advanced your clinical expertise into different areas but that same thing applies. You are preparing to intubate a patient and know that ultimately, that tube needs to secure the airway. But you have the option of DL, VL, intubating with a bougie or without, and many other preferences.
These preferences come from having a strong foundation of knowledge, deliberate practice and mental rehearsal of a skill or situation, reflection on your previous practice of what works and what hasn’t, reviewing the available literature and evidence, and ultimately distilling all of these components down to what you practice.
What ultimately matters is what you do that contributes to a successful patient outcome, not necessarily how you got there. If you keep that in mind, you have discovered the recipe for successful clinical practice.
The Recipe for Excellent EMS Care
1 Part Judgment 1 Part Knowledge 1 Part Skill 1 Part Caring 1 Part Reflection on Your Practice
Each component here contributes to your success as a clinician. If you are reading this, if you are immersing yourself in the knowledge to be gained from FOAMed, and if you care about your practice and are taking the steps to stay educated and reflect, you already possess the recipe for being a successful clinician. It is a recipe that is developed and refined over time. We practice clinical medicine, because we will never have the perfect recipe.
Wait, what about the recipe for perfect rum punch? That remains to be determined.
Tom Latosek, MS, NRP, CCP-C
Tom is a practicing paramedic and EMS educator who is interested in EMS research, and advancing the profession of EMS through education. Tom has practiced in a variety of EMS clinical settings and teaches a variety of courses for a healthcare education company. Tom holds an MS in neuroscience and a bachelor’s degree in biology and psychology and is currently a second-year medical student.