Experience: Sweating the Small Stuff

Dr. Weingart at Emcrit gave a brief but excellent podcast about “Logistics vs. Strategy.” Go have a listen and then report back.

His point was that it’s not enough to decide what the best course of action for a patient may be. Most of our training and planning is focused on this — what’s the diagnosis? The plan? The treatment? But this is only half the battle. In a war, this would amount to our strategy, and wars aren’t won by strategy alone. You have to implement your strategy through sound execution of the basic fundamentals of logistics and tactics — keeping everyone fueled and fed, maintaining the vehicles, setting up supply lines, and so on.

In medicine, the same problem applies. It’s one thing to say, “I’ll C-spine, assist with ventilations, and transport.” That’s your plan. But can you make it work? It may be easy, but it may be hard. All three of those items — immobilize, bag, and hoof it — are potentially difficult skills, and how they occur will depend on details like the patient, the environment, and the circumstances. I know you can say “assist with ventilations,” but if I hand you a BVM and a mannequin, can you do it? Now, can you do it an a real human? How about this human who’s tied to a board and being maneuvered through a house? Oh, you haven’t tried that before? Well, go ahead and figure it out. But wouldn’t it be nice if you’d done that before the sick patient needed it?

Experience is where we learn this. We talked about how experience involves learning how textbook clinical events actually present in real patients; experience also involves learning how textbook skills are performed in real patients. You may be able to articulate how to apply a cervical collar — in fact, it’s a very simple process, so I hope you can. But until you’ve actually tried to do it, can you flip up all the right plastic bits, and insert Tab A into Slot B? Can you hold it in the right hand while securing it with the other? Can you do it from the other side? How about from behind? While standing and kneeling? Heck, do you know where the collars are?

You might get all of it right the first time you do it. Or you might fumble, but it’s easy enough, so you figure it out and the second time, you’ll have mastered it. Or maybe it takes a few times. Or maybe it’s a difficult skill like intubation, and you’ll need dozens of attempts before you’ve made all the mistakes. This is the process of developing experience. Even if you do get it the first time, until that happens, you won’t know whether you can do it or not.

But you can speed up your experience by doing the right kind of learning. Hopefully you know the basic functioning of your equipment, but how often are our situations in the field straightforward? How many times have you seen a veteran provider pull off some trick that you never imagined was possible, just because he understood some subtlety of the equipment or of pathophysiology? Have you ever used towels to modify a carseat for a small infant? Is it safe to do so? What’s the exact maximum load weight of your stretcher, and how dangerous is it to exceed that? If you trim the length of the prongs on a nasal cannula, will it compromise its effectiveness? If I took away or broke half of your equipment, could you make do with the other half? Is your portable radio waterproof? Do bloodstains come out of your uniform beanie?

You’ll learn it all eventually. But asking the questions ahead of time will make you a better provider sooner.

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