game planning in medicine

Monday, December 31, 2012

The last weekend of the regular season in the NFL presents some games that are meaningful and to the victor, a spot in the playoffs is the reward. Some games are less important and teams who have secured their playoff spot often rest their star players. And of course, there are games where players play for pride because their year will soon come to an end. On winning teams and in winning organizations, players seem to shuttle in and out of the lineup and the team’s performance isn’t necessarily affected. Star players make a difference but their backups have learned how to work within the system that is in place to win football games.

Systems have finally made their way into medicine as well. New generations of students and residents are taught to care for patients in ways that might benefit patient outcomes, decrease mistakes and minimize potential complications. While this may sound like an assembly line approach, it tends to work when critical care that needs to be provided, crosses many physicians and specialties. The multiple injured patient challenges many hospitals and those that are designated trauma centers tend to provide care in an organized manner. Practice scenarios are repeated so that doctors, nurses and support services like lab and x-ray know their roles, where to stand and in what order tasks must be done.

During the initial evaluation and resuscitation of a trauma patient, an ideal team has many members, each having their own role and may include two physicians, two nurses, an assistant, a respiratory therapist, a lab tech and an x-ray tech. The lead physician is stationed at the head of the table and is in charge. There should be only one person giving orders, otherwise with more than one person yelling orders, the scene becomes chaotic and the chance to make a mistake increases. The lead physician is also responsible for evaluating the upper part of the body including the airway. The second physician is stationed at the side of the patients and looks after the torso and extremities. The nurses split the duties of IV access, medications and monitoring. The assistant often helps with placing tubes into the patient, as well as helping move the patient safely. There may also be a scribe, a key person responsible for documenting the play by play, since too many things happen too quickly for everybody to remember. It prevents medications from being given too frequently or being forgotten, tests to be ordered appropriately and results given to the responsible doctor or nurse.

Once the patient is stabilized, lab, x-ray and other tests may be needed and moving the patient is a finely choreographed skill that needs cooperation between many people. Often it is difficult to know if a spinal cord injury is present and the patient is handled carefully to prevent paralysis. Log rolling a patient to check the back for injury or to move them onto a board that will allow transfer to a CT scanner or other treatment area takes many hands, especially if the patient is comatose or combative.

Aside from the staff, there are diagnostic and treatment guidelines used to help with diagnosis. It’s too easy to miss a significant problem if more than one catastrophe is happening to a patient and attention is diverted one and the other ignored. More than just a checklist, it’s a repetition of the physical examination and reviewing the diagnostic test results that help minimize the miss rate. And good diagnostic plan leads to good therapeutics. Knowing that a problem exists is the first step in beginning to treat it.

In the past, ill patients were surrounded by too many good intentioned people and more than a few gawking bystanders drawn to the scene as they wandered through the ER. Streamlining the system makes a difference and allows parts of the team to be interchangeable. That recognition probably hurts the egos of a few physicians but that is the tradeoff that a well-oiled machine brings to the bedside. Better care tends to occur when physicians fit the role they are supposed to play.

There is always a captain of the ship and that is the physician at the head of the bed. Decisions and responsibility fall come with the job but success depends upon the team. It might be the same mantra that can be attributed to a backup quarterback who steps into a good system, was surrounded by a fine supporting cast. Players need to know their role in the system and to understand the game plan to come up with a winning effort on the field and perhaps in the trauma suite.

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