Thursday, May 31, 2007

The devil is in the details...or is it?

I recently had some comments from instructors and students about material in one of my books. I researched the answers, consulted with Ed Dickinson, our medical editor and replied to the queries. I always enjoy and appreciate these comments.

It was after I replied that I began thinking about a bigger picture. Let me explain.

The first comment was in reference to how many weeks a woman is pregnant. One source said 37 - 40 weeks while another was 38 - 42. Which was correct? The answer: pregnancies are "scheduled" to last 40 weeks from the first day of the last menstrual period (LMP) until birth. Some babies come early, some come late. A (very) few are born on the due date. Not an exact science. We use the 38 - 42 week numbers to reflect this fact.

The next question was in reference to flail chest. The book states a flail chest is 2 ribs broken in two or more places. The reader asked if it should be three or more ribs broken in two or more places. Good question.

This is what the trauma sources say:
  • Lippincott trauma manual says 2 or more in two or more places
  • Tintinalli and Rosen say three or more in two or more places
  • The Mattox trauma book says "severe thoracic injury causing paradoxical motion of chest wall segments has been termed a flail chest."
  • says three ribs broken in two or more places
  • says two ribs broken in two or more places
  • PHTLS 4th says two or more adjacent ribs in two or more places

That's about as clear as mud isn't it?

The last questions is: Why do we say that we can suction for no longer than 15 seconds? Another good question. The most likely answer is that the longer we suction the more hypoxic the patient gets and someone thought 15 seconds was a good guideline.

But the real questions is: What happens if a patient vomits for 20...or 30 seconds?

These three issues actually leave me with a larger concern. How do we get our students and practitioners to think critically when we present (and test) very concrete facts? Lets look at the three questions again from a field perspective:

Pregnancy - the EMT asks how far along the patient in apparent labor is. 24 weeks (holy crap) 36 weeks (early but do-able) 42 weeks (really uncomfortable overdue mom).

Flail chest - is the segment unstable and interfering with breathing? Do we care--or even have the time to count--how many ribs are broken?

Suction - This patient won't stop puking. If I keep suctioning he's hypoxic. If I don't suction and start bagging I push the yuk down his throat and he dies in the ICU later from aspiration pneumonia. (The point: some patients die despite our best efforts to save them.)

These questions from instructors and students are real and necessary. There is an urgency to know these facts because they may be on exams. No one suctions or treats a flail chest unless they get the EMT card.

Do we need the 15 second and two/three rib rule or can we be more practically oriented? Do students and new EMTs need concrete rules or can they apply concepts and consequences under pressure?

Can we test without these exact numbers? Are they necessary facts or traditions that holds us back from better clinical thinking?

Enough for today. Add a comment to tell me what you think.

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