Category: Critical Care Practice

Keeping Up with the “Literature,” Part 2

Earlier I shared a post about how Eddy Joe Gutierrez stays on top of the critical care literature. I mentioned that I also use social media/podcasts/blogs/etc to help me stay on top of things and promised a little more later.

So, I put literature in quotes in the title, because a lot of people don’t consider this sort of thing to be “the literature.” And in the strictest sense of the word, it’s not. However, in 2022, we can learn a lot about the current state of critical care research and practice from these non-traditional sources (hence the entire raison d’etre of this blog). Many of the podcasts, blogs, etc out there cite sources for their information, it’s not just “expert opinion.” And, these tools make it easy to digest info in 2 main ways: crowdsourcing and enabling on-to-go learning.

Crowdsourcing, if you’re not familiar, is the concept of getting input from a variety of people in order to answer a question or deal with a problem. It’s the 21st century version of sharing the work. Social media is a great way to crowdsource your literature review. Because there are so many critical care professionals out there on Twitter, Instagram, etc., and they can all post about the latest literature that interests them. By following a wide variety of people, you can get posts about a wide variety of interests in easily digestible bites.

The other huge benefit to this is the on-the-go nature of this medium. I’m busy. I’m sure you are too. I don’t have a lot of time to sit down and read a journal. But, I do have time to listen to a podcast (more on that in a bit). I can also listen while doing other things. My favorites are to listen during my commute, while mowing my yard, and while walking my dog. I used to listen a lot at the gym as well, but find that I can’t focus as well, so I reserve those for podcasts about things I don’t have to concentrate on (typically topics I already know and just need some refreshing on). I also have time to scroll through Twitter or Instagram while I drink my coffee in the morning. These posts are short and I can bookmark anything interesting to look at later.

OK, this post is getting a bit longer that my usual, and I’ve got a lot more to add, so I’ll save the nuts and bolts of how I manage all of this for next time.

Keeping Up with the Literature

If you’re like me, your inbox is full of stuff that is crying for your attention. And you likely have a stack of journals in the corner of your office for “when I get some time to read.” There is a non-stop onslaught of information coming at us every day, and this is especially true in critical care. If you’re also like me, you probably have said, “I want to make sure that I’m giving the best possible care to my patients, but how can I stay on top of all the newest literature?”

In this great blog post and podcast episode, Eddy Joe Gutierrez shares with us how he stays on top of things and keeps up with the latest and greatest in critical care literature. I love a lot of his suggestions. Some I currently do (Critical Care Reviews is essential!) and some I’m thinking about implementing in my own life. One thing I have found super helpful in keeping up with things in social media/blogs/podcasts, hence, this site! I’ll be doing a separate post on how I manage all of that and use it to help me personally stay on top of things. Right now, check out Eddy Joe’s strategy to keep up with the literature.

Being Ambidextrous

I want to highlight an episode of our podcast, Critical Care Scenarios, today. But, it’s an episode I had nothing to do with. My co-host, Brandon Oto, has started an occasional series called TIRBO (The Intermittent Rantings of Brandon Oto) where he just talks for a few minutes about a particular topic. In this episode, he discusses doing certain procedures with your non-dominant hand. I wanted to share this in case readers aren’t regular listeners to the podcast (why aren’t you??). Also, I thought I’d take a minute to add in some of my thoughts.

I teach a lot of procedures. I teach our APP Fellows. I teach procedures to our students at Georgetown University. I do central line workshops for all the new APPs/CRNAs in the Department of Anesthesiology at UK. And one thing I’m constantly harping on is positioning. Positioning the patient and positioning yourself. This is the number 1 cause of procedural troubles (I don’t have RCT data to back that up, but I stand by it).

Twisting and contorting yourself not only is a good way to hurt yourself, either acutely or over the long term, but it’s a great way to make a simple procedure really difficult. If you’re uncomfortable, you’ll subconsciously rush and take short cuts. Your body wants to make the discomfort stop and the best way to do that is to stop doing what’s causing the discomfort (i.e. the poor position). But, most critical care providers are stubborn and so we won’t quit until we get it. So, we rush. Which in the long run actually prolongs things.

So, how does all this related to using your non-dominant hand? Sometimes the best position you can get into is going to be a compromise. I’m right handed, so I prefer to put femoral lines in standing on the patient’s right. But, that’s not always an option. Or if it is, the right femoral might not be good. So, I can reach over the patient to get to the left femoral, but that’s sometimes too much of a stretch (pun intended) and hurts my back). So, I can stand on the other side and twist myself to use my right hand, but that’s usually hard on my aging spine as well. So, I’ve developed the ability to go left-handed.

Similarly, I always teach to set your supplies on a table to your right (if you’re right handed) to do IJ line from the head of the bed. But, frequently in my place, that’s where the vent is and I might not be able to get a table there. So, I set my supplies up on the left. I can then twist and contort myself (a no-no), or I can use my left hand.

So, when you’re learning, learn with your dominant hand. But as you grow in your skills, branch out and learn to do some stuff with your non-dominant hand. It really comes in handy at times.

Diagnostic Reasoning in Critical Care

When I was a nurse practitioner student, I wanted to do as many procedures as I could so that I could be proficient. My advisor told me, “I don’t care if you do a single procedure in school. I want you to focus on learning to think through a problem, formulate a differential diagnosis, and develop a treatment plan. I wasn’t really happy about that, as I really loved procedures and thought that’s where my focus should be. Making a diagnosis and formulating a treatment plan was easy. I thought.

Now, I teach ACNP students and find myself saying the same thing! I don’t care about students learning procedures. That’s one of the easiest parts of critical care to be honest. Of course it takes repetition to get good at procedures, but the critical thinking, that’s the tricky part. (Sure, there’s no reason that you can’t develop procedural skills and critical thinking.)

In fact, the really tricky part is making the diagnosis. You can look up treatment plans in UpToDate and at least get an idea of what to do. But making the diagnosis, that’s hard.

Recently, we had Andre Mansoor on the Critical Care Scenarios podcast to discuss the art of diagnostic reasoning. Dr Mansoor is the author of a great book on the subject, Frameworks for Internal Medicine. It is the best guide to diagnostic reasoning and differential diagnosis formation that I’ve read. I use it when I teach my ACNP students and when I create scenarios for simulation. In the podcast, Dr Mansoor goes through his thought process when approaching a patient and beginning to formulate a differential diagnosis. The book goes into even more detail, taking common presenting complaints, breaking them down and helping the practitioner narrow the list of possible problems based on the evidence collected in the history and physical exam, and then adding in other diagnostic studies.

“What would you like us to do?”

This is probably the best question that can be asked surrounding a new consult. I’ve been asked it when calling consults and I’ve asked it myself when receiving consult requests. It sometimes sounds aggressive and even jerky, but it’s not. It’s seeking a moment of clarification. Looking to define why exactly the consult is needed.

Consults are not benign. Like everything else we do, there are consequences as well as benefits to asking for a consult. You’re adding to someone’s workload, however large or small the request. We often think, “it’s a minor issue, won’t be any trouble for them.” But even a “minor” issue requires a consultant to review a patient’s record, see the patient, make recommendations, write a note. There’s really no such thing as an inconsequential consult.

In addition to the effect on the consultant, there’s the added burden on the patient. “How could a consult burden or be detrimental to the patient?” you may ask. “Too many cooks…” is the phrase that comes to mind. The more teams that are involved, the more complicated things become. Again, there’s really no such thing as an inconsequential consult.

All of these downsides are perfectly acceptable if the consult is needed. But often, it isn’t. We often consult a specialist for something that we don’t really need a specialist for. Sometimes it’s a knee jerk reaction to a problem. “New AKI, consult renal.” “New afib? Better call cards.” But the fact is, many times the primary team, especially an ICU team, is perfectly capable of handling these issues.

I know an attending who likes to break her specialty into “101” and “401.” The basics and the upper level stuff. 101 is the bread and butter that an ICU team should be able to manage. 401 is the higher level stuff where you need a consultant.

“What do you want us to do?” is the question that clarifies that. It prevents the knee jerk reaction and forces you to stop and think, “do I really need this consult?” If the answer is “yes,” by all means, call it. Because the flip side of that coin is just as bad (if not worse).

Waiting until it’s too late for the consultant to be of any help is bad for the patient and the consultant. This is my approach to, “should I transfer a patient to the ICU?” If there’s any doubt, call. I’d rather go look at a dozen patients who are safe to stay on the ward than have to admit a patient who is crashing and likely beyond saving because the service was afraid to call.

So, I guess what I’m saying is, err on the side of caution, but always ask yourself, “what would I like for them to do?”

One-Handed Knots

I’ve been doing a lot of procedures lately and I’ve been thinking about how we tie knots. Strange thing to think about, but we do it a lot. Most of the procedures that we do in the ICU require some suturing (chest tubes, arterial lines, central lines) and suture needs to be tied.

Now, most ICU providers who aren’t surgeons probably use an instrument tie for this. And it works fine. But I did a few surgical rotations in school and first assisted on lots of different cases. So the surgeons and surgical PAs taught me their ways. So the one that I use most often is the one-handed knot.

Once you get facile with it, it’s faster than an instrument tie. It also allows you to have a hand (somewhat) free for other things. I particularly like it when I’m putting in a line that I’d like to keep a finger on until that suture is good and secured. And – I think – it makes you look like you have some special skill.

There are lots of good instructional videos out there, but I really like this one from Rishi Kumar. He’s an intensivist (and a good follow in general, BTW) so he approaches this from that perspective. In this video, he walks you through the technique and explains why, as an intensivist, he uses the one-handed knot. (We have mostly the same reasons, so that probably biases me a little as well, haha!) Like him, I also prefer to tie left-handed, even though I’m right-handed. I don’t really know why, I guess that’s how I learned and it’s all muscle memory at this point. It probably is worth practicing with both hands and being ambidextrous with the technique.

You can get a knot tying board like he uses, or just get some extra suture (or regular old thread) and practice on anything. I like his steering wheel suggestion. I used to practice by sewing up rips and tears in my kids’ stuffed animals. Now that we have a puppy, there is ample opportunity to practice on her toys when she loves them too much! I also recommend wearing gloves when you practice because the feel is slightly different. But, please don’t wet your hand (like he suggests) if you’re practicing on your steering wheel in traffic!

“Your Presentation Sucks”

One of the bigger aspects of critical care practice, especially for those of us in academics, is giving presentations. These may be very large, such as presenting at conferences and meetings, or small, delivering a quick talk to a group of learners. All of us have the experience of sitting through bad presentations. And we’ve all heard the phrase, “death by powerpoint.” As someone who started in web design and who considers themselves someone with an eye for good design and the importance of visual aesthetics, this is especially painful. But, for a long time, I just did my presentations the same way. I just thought that was how it had to be.

But, then I met Ross Fisher (we can say met when we’ve only met online, right?). Ross is a pediatric surgeon in the UK but he has become well known as “that presentation guy.” He has a great website, p cubed presentations, devoted to helping medical professionals to improve their presentations. And, to be clear, this is not just about better slide design. It’s about better presentation design. I’ve totally changed the way I give presentations based on a lot of Ross’ work and I think for the better.

Critical care professionals, no matter what your role or level of training, should look through the site and try to improve your presentations. We all want people to care about what we’re talking about, and these tips will help with that. The site covers lots of aspects of presentation design and delivery, but also covers different types of presentations. This is especially helpful in addressing the problem of, “well, sure, better presentations would be good, but I’m presenting a bunch of research data, so it won’t work.”

Here is a nice video of Ross discussing his strategies on presentation design and delivery at Queen’s University Pediatric Grand Rounds.

The Art of Diagnosis

I think one of the hardest things to do in healthcare, and one of the hardest things to teach, is the process of forming a diagnosis. We talk about pertinent positives and pertinent negatives (which in and of themselves can be confusing to students) and about horses and zebras, but overall, we still don’t really do a great job with this. Brandon Oto over at his blog, Critical Concepts, does a great job talking about the importance of making a diagnosis, that is, naming it. Not just saying that the patient has tachycardia, but venturing a guess as to why. And I think that’s a critically important first step. And a scary one. By venturing a guess, we open ourselves up to being wrong. But, that’s how we learn and grow and get better.

But how do we go about making a differential diagnosis list? Do we just take everything that fits the presenting complaint and then start testing? Well, that seems to be what a lot of providers do. We test and test and test some more. But, there is a big downside to testing and in fact, when we test not to confirm a diagnosis but to establish one, we may cause more harm than good (VOMIT).

Dr Andre Mansoor from OHSU is one of the best teachers of diagnostic reasoning and the process of forming a differential diagnosis that I’ve come across. I try to use his techniques and processes not only in my own practice, but in my teaching. I actually teach a course called Diagnostics and Clinical Reasoning at Georgetown University in the Acute Care Nurse Practitioner program. So, I’d like to recommend Dr Mansoor’s website, Physical Diagnosis as well as his book Frameworks for Internal Medicine. This is one of many good talks he gives covering these principles and is a great overview of what you’ll find on his website and in his book.

Palliative Care in the ICU

We frequently have to have difficult conversations with families in the ICU. And often, Palliative Care falls to us as well. Dr Jessica McFarlin is one of our Stroke Neurology attendings and a Palliative Care attending here at UK as well. This is an older episode, but Dr McFarlin was on my podcast, Critical Care Scenarios, way back in April and May of 2020 and did a great 2-part discussion of Palliative Care in the ICU.