Kane MT. The assessment of professional competence. Eval Health Prof 1992;15:163-82.
If someone asks why a medical professional deserve to work in a public emergency medical system, despite a degree (as many others in different fields), experience (subjective) and a fist of courses (mostly individually chosen and not institutionally validated) there is nothing objective that demonstrates that this professional was, and still is, eligible for this kind of job in terms of competence.
Certification of clinical quality is something missed in action in the jungle of Health Systems in general and in Emergency Medical Services in particular.
We have generic admission criteria but no instruments to monitor on a regular basis the adequacy of clinical competence for medical professionals who work in emergency field.
We spread education, giving competences equally distributed to all medical professionals, despite any specific need.
Cultural needing are not a question of democracy.
They are specific for each person who works in a certain field and are conditioned by different personal attitudes and everyday clinical practice.
We waste time, money and human resources giving, in large part of cases, unuseful informations to the wrong persons at the wrong time of their working careers.
The fact is that we do not have a clear idea of who and which competences are needed to be a good medical emergency professional.
None stated which skills and which clinical practices, in quality and quantity, are needed to achieve a minimum level of competence.
The paradox of the demonstration of the effectiveness of the parachute with randomized controlled trials, in accordance with the method EBM (The Parachute trial), provocatively poses a fundamental question:
A 2006 article published in the BMJ Controversy Parachute approach to evidence based medicine brilliantly responded to this question.
It contains some examples of very common diseases in developing countries (HIV, dehydration in children, postpartum hemorrhage) whose remedies, implemented previously than results of relative trials where available, have saved thousands of lives.
The authors conclude that:
1. Randomised controlled trials are usually required before new interventions are implemented
2. If other evidence of effectiveness is good, and potential benefits large, the resultant delays may be unethical
3. Examples from poor countries show the price of delaying interventions
The triad of decision-making at the base of the construction of Evidenced Based Medicine provides an integrated approach between explicit data (scientific evidence derived from trials of good quality) and tacit data(clinical expertise and the patient’s needs).
The clinical decision is derived from the combination of these three factors:
• Scientific evidence
• Clinical Experience
• Needs of the patient
But when defining the level of quality of evidence those derived from clinical practice and experience are relegated to the base (lower level) of the pyramid whose apex (higher degree) are the evidence derived from studies on large patient populations.
Randomisation and de-personalization of scientific research, while eliminates everything that is “non-evident” in medical research, and is well suited to a concept of public health, on the other hand maintains an unbridgeable gap with daily clinical practice that is focused on the care of the individuals.
But in practice what we can do:
We can and we must go beyond the exclusive use of EBM in medical research and clinical practice.
The adoption of an integrated approach between the explicit scientific evidence derived from clinical trials (EBM) and a “patient- centered approach” derived from the clinical experience, should be a stimulus and an intent to the future development of our approach to the critically ill patient.
It must always be clear in the mind of the emergency medicine professionals which treatment is scientifically more correct for a given disease, but he must contextualise, and implement it for the particular patient who is dealing with at that time
When something like that happens the first thought for an HEMS professional is:
IT COULD BE ME!
Then you start to rationalise the situation, mostly in a technical and non emotional way, and arrive at the conclusion:
NEVER WOULD HAPPEN TO ME.
There are many reason, in my opinion, why we arrive at that.
We all have family and friends to care about and who take care of us. And we can’t even imagine them devastated by grief.
Our major concern is about patients health and not about our safety.
And finally, we are humans and human being self-protect their inner fragility, avoiding to hurt themselves thinking about death, especially their own .
But I know, and always will. that IT COULD HAVE BE ME despite any protection and self-lie.
Cause even the 6 persons who died in the crash had family and friends that now live in a devastating grief.
Even them were taking care of patients over they own safety.
And also them were humans, like me.
So WAS ME!
Today a part of me ideally died in that crash.
Tomorrow a new day will begin, but from now on things will look different.
From a practical clinical point of view, after the 2016 update of the SSC (Surviving Sepsis Campaign) guidelines we have two references when comes to deal with a potential septic patient.
2016 Sepsis 3 definition and early management.
Let’s see how to treat, based on top evidences, a real patient in the the pre-hospital and emergency department time window.
But, first of all, the definitions:
Both the guidelines now agree that:
“Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection“
“Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) despite adequate volume resuscitation”
The state of the art: Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects.
A radical change in definition and concepts of Sepsis and sepsis management . From SSC to Sepsis 3. Not a worldwide accepted change in clinical practice. If you are interested in more about go to Sepsis folder
A complete guide to approach at children with decreased level of consciounes is for me a constant friend in my clinical practice.
Less is better when comes to Oxygen therapy. This very well done Italian study despite his early unplanned termination (cause of a earthquake that hitted the centre of Italy) confirm the trend toward reduced mortality in conservative targeted oxygen administration versus conventional liberal therapy.
Hypoxic lactic production is a mantra in both patho-physiology and clinical practice. In this article the author gives different interpretation of the phenomena. One of my favourite.
This systematic review and meta-analysis clearly demonstrate how in both cases CA and CS, ECMO support improve mortality compared with standard techniques. Every emergency system has to consider this option.
Rare but dramatic condition among all the epileptics status need the best of EB treatment. Here is the latest reference guidelines released by one of the most important international scientific society. Must read.
Traditional performance measures and a proposal for a new more complete model for Clinical Performance Benchmarking. An efficiency and quality assessment method that prehospital systems need to acquire.
Debating about with model of EMS is the more efficient in performing out of hospital CPR? This systematic review and meta-analysis affirm that physician based models have better performances than non physician based ones.
HEMS vs GEMS. Ground or air transport in traumatized patients? This article is not the end of the story, but pose a good base on how HEMS can be a better alternative to rescue and transport trauma patients.
That ‘dottorino’ grown up and experienced a bit now but never stopped studying and learning from everyone, and this is my wish for 2017, to every professional who works in emergency medicine:
Never stop studying even if you feel to be “the best”.
Never stop listening to everyone, they can have something useful to say.
Open your mind to innovation and be ready to change everyday.
Be ready to start again even in the worst moments of your career; every start is the beginning of a better life.
You can look at the future just if you have a steady past.
Good 2017 to all MEDEST friends and followers.
Great summary about fluid responsiveness and ultrasound evaluation through caval index (IVC collapse). Must read.
Your patient is dry….or so the night docs tell you, having had it drummed into them for the past few hours into the morning by the nursing staff. How are you going to sort this, is there a bigger issue with the patient, do they need the magic pressers, just IV fluid…..or, do you reach for the good old Echo probe???
Those of us who are echo obsessed would obviously jump in with this modality immediately…the knobologists path! But are we doing this in preference to other things and what are it’s merits in assessment off a suspected volume depleted patient?
In critically ill patients at risk for organ failure, fluids can be friend or foe. We all want to increase cardiac output and oxygen delivery, but some patients just act up and you see worsened or no change in cardiac output, oedema, worsening ventilatory parameters and mortality! This blog…
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