Lessons in Transport - Cognitive Biases in Critical Care Transport

Lessons in Transport - Cognitive Biases in Critical Care Transport

As critical care transport professionals we are often perceived as an action oriented specialty. We frequently pride ourselves on procedural excellence and efficiency. (a difficult intubation, or fast scene-time etc.) However, the reality is that we spend the vast majority of our patient care time engaged in cognitive behavior... in THINKING rather than acting!

Because of this, it is imperative that we make every possible effort to understand how we think while caring for others. In addition, we should be aware of some of the cognitive biases that threaten our thinking processes, decision making, and thus the patients who place their trust in us.

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Lessons in Transport - 2/18/2014

Lessons in Transport - 2/18/2014

It is 2am on a cold, dark, winter night and you are dispatched to a small rural hospital to transport a patient by ground with a GI bleed back to UCMC medical ICU. Enroute dispatch notifies you that your patient has deteriorated and is profoundly hypotensive. The ED physician at the outside hospital is attempting intubation for airway control. On arrival you find a middle-aged male with all the classic stigmata of end-stage liver disease. More importantly he has a systolic blood pressure of 60 and a HR of 130. A literal fountain of blood spews from the patients mouth, around a successfully placed endotracheal tube, and is now beginning to pool on the floor. You know this patient needs massive resuscitation from his likely bleeding esophageal varices... but you are 55 minutes by ground to UCMC and know that your patient will not survive the transport unless something is done to control the bleeding...

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Lessons in Transport - Surviving Sepsis Part 2

Lessons in Transport - Surviving Sepsis Part 2

"Around every 3rd heartbeat someone dies of sepsis"

Blood Product Administration:

  • Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration has decreased to < 7.0 g/dL to target a hemoglobin concentration of 7.0-9.0 g/dL in adults (grade 1B).
  • FFP NOT be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).
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Lessons in Transport: Surviving Sepsis

Lessons in Transport: Surviving Sepsis

We routinely transport patients with severe sepsis and septic shock by both air and ground. Take a few moments to review these high yield management pearls from the 3rd edition of the Surviving Sepsis Campaign Guidelines.

Initial Resuscitation:

  • Goals during the first 6 hours of resuscitation:
  • CVP 8-12 mmHg (a debate on the utility of CVP or lack their of is beyond the scope of this LIT)
  • MAP >  65 mmHg
  • Urine output >  0.5ml/kg/hr
  • Central venous or mixed venous oxygen saturation 70% or 65% respectively (grade 1c)
  • In patients with elevated lacate levels we should target resuscitation to normalize lactate (grade 2c)
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Lessons in Transport: Avoiding Medication Errors

Lessons in Transport: Avoiding Medication Errors

It takes an estimated 80-200 correctly executed tasks to successfully administer a single dose of a medication to a critically ill patient...

Our reality in transport medicine...  We routinely work in an environment that is prone to medical error. An environment that is...

  • Dynamic and potentially dangerous
  • Fast paced... where speed is perceived as excellence
  • Limited in space, resources, and personnel
  • Built on inferred indications with little access to confirmatory tests
  • Frequent patient care hand offs of high acuity patients
  • Defined by actions and inaction that have immediate consequences with little recovery time to stop sequential errors
  • Not reproducible... No mission is ever the same
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