Introduction
This work is to be approached from the point of view of students , who we all are, wishing to develop a functional point of view from an
analytic perspective. The current assets promoting the spread of knowledge
provide such a diverse number of points of view that an analytic approach is always
the right approach to the written word. We are working from from a knowledge
perspective that is incomplete and evolving.
Q. How does one write
usefully in any field that is continuously evolving and has a steady stream on
new information , people , and devices or tools that continuously change the
equation?
This is important to conceptualize because our
world is filled with new methods of capturing and displaying information with
the result that virtually every morning there are nuance changes to the state
of the art.
A. Focus on the
missions that you will choose to be involved in executing to first understand
the problems and then the actions necessary to solve them. The personalized
approach then will continuously morph as your personal “capability equation “
changes.
This would be easy if the
world delivered a fixed set
missions all packaged with
appropriate labels for you to address at your leisure . The real world of
course delivers problems at the most inconvenient times and with subtle
variations that may or may not be obvious to the un-initiated. Thus it becomes
necessary to approach any serious task from a perspective that deep knowledge
will be required to allow one to cope with the many variants one will
encounter.
This work is designed to provide a series of ideas that will
form a point of view designed to illustrate the problem and allow one to
develop a tool kit of strategies and real tool skills that will allow one to
provide a rational scaled response as problems are presented.
The discussion in this book relates to Airway Management
which has proven to be one of the most scary and humbling of Medical fields
because the failure to handle oxygenation effectively in a few minutes can
result in death, brain injury, and personal despair for the EMT or MD who ends
up with ,for example, an endotracheal tube in the esophagus .
Control , and the
search for it, is elusive for neophytes .
One typically starts life
with abundant confidence that whatever comes up will be handled by personal
inventiveness and brilliance. This confidence , sadly is crushed , the first
time that you have a close call or real failure. Those with luck will be
rescued in time to prevent making the
patient pay too big a price for your weaknesses. Clearly realism must be
combined with a careful approach to minimize risk and have options to prevent
disaster.
Medical
teachers and students can look at the art of training pilots as a guide to
safety and emergency preparedness. As a pilot who has developed a modest skill
level including Instrument flight and night operations flight it is clear to me
the rather haphazard approach to skill acquisition and testing carried out in the Medical arena needs
serious work.
Q.
When was the last time you were prevented from putting a patient to sleep or
stepping into your ambulance because of failure to pass a multi- function
scheduled skill test?
A.
Never I suspect .
The good news is that you don’t need to know everything and
you don’t need to be a severe academic. You must only know a depth of knowledge
that will enable you
· to assess your own limitations,
· know which tools are available ,
· how well you can use them,
· know and listen to the right people to support you own
weakness,
· be alert for
ideas and people who can assist you in your lifelong quest for knowledge.
To this end you will likely
need to join a “Tribe” of people interested and able to exchange knowledge .
The Society for Airway Management “ or the UK DAS would be such a tribe and in
addition your own hospital could have an “ Airway Competency Group” that was
willing to declare standards and leadership for pursuit of excellence. Could you
develop the best program in your area for this kind of learning? Unfortunately
there are many areas of Medical competence to be addressed at the same time and
this speaks to the need to develop declared zones of interest “ ie. Airway
Leads “ for the many types of skill required for modern practice. Should you be
saddled with the task of being a hospital Department Head or EMS Medical Director then it is your duty to
have all staff involved in one or the other knowledge bases so that a state of
the art skill level is achieved in all areas.
The “ Airway Lead”
has several missions that are measurable by the airway management outcomes of
the department
1.
Does the “Airway
Lead” have state of the art knowledge ,and if not, how is this to be developed?
2.
Does the “ Airway
Lead “ have a real time knowledge of the local hospital state of practice and
are the local disasters properly investigated and measured?
3.
Does the “ Airway
Lead” understand the learning needs of other department members and whether
they are supported for training and practice?
4.
How does the local
program rank in the world of airway “Management Excellence” generally accepted
measures.
5.
Does the “ Airway
Lead” provide tools necessary so that staff can operate according to current
norms?
The
development of appropriate systems can only be done when the goals of the
department are clearly vocalized and measured in such a way that sub- standard
practice is not possible without bringing to bear a full disclosure. When this
is done change can be continuously implemented until excellence is achieved.
Great
guidelines are now available for development of policy and the ASA Algorithm
rewritten in 2013 “Practice Guidelines for Management of the Difficult Airway “
and the new Guidelines 2014 written by
the UK DAS “DAS Intubation Guidelines
2015 Update” are current examples that must be studied for comprehension of the
consensus knowledge available. These will be mined later in the piece for
specific strategy presented.
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