A nurse walks up to a
physician, “The lab just called for the asthmatic in bed 14, the lactic acid is
6. I’m going to start the sepsis protocol”.
“No need,” says the
physician, “continue the albuterol”.
“But the lactic acid
is high. We have to follow the protocol.”
“The patient has a
lactic acidosis because she’s hypoxic from her asthma.”
“That may be so, but
we have to follow the protocol, it’s hospital policy.”
**********
When interpreting the lab test or any new information, we
need to put that new information into the bigger context of our patient. Sounds
obvious, but it’s easy to fall into the trap of a knee-jerk reaction to do what
we have always done (our custom) or what the hospital policy is.
Custom and policy usually give decent results and create
consistency. Most of the time, the custom and policy are good enough to get the
job done. However, from time to time they give us the wrong result. When we get
the wrong result, we likely misapplied our rules to the situation in front of
us.
The flexibility to take a step back, view the bigger
picture, and see if custom or policy actually applies to the problem at hand
will serve us well. Those who are inexperienced will fall into this trap, but
on occasion those with the most experience may fall into this trap. Those
with little experience may tend to cling blindly to a protocol. The protocol
gives them something solid to hang on to. Those with the most experience may be
so ingrained in their ways that it’s difficult for them to see something
differently. Essentially those with the most experience may have their our own,
personal, unbending protocol.
For the practicing clinician, the ability (or humility in
some cases) to take a step back, be critical and question what the other
possibilities in a situation are is key. To do this in every situation would be
laboriously slow and wasteful, but to on occasion question if what we are
doing is the right thing to do will bring us a long way as clinicians.
In the case above, many conditions can cause a lactic
acidosis. Sepsis is just one of them. Someone should question whether the
protocol applies by asking themselves questions like:
- · Are we using the right tool of this situation?
- · Or are we using a tool designed for a different situation?
Customs and protocols are very useful, but we should use
them with suspicion. We should ensure that they fit into the big picture of
what you are supposed to be doing.
Those who do not question themselves can be like machines
and follow policy blindly, but thinking clinicians take the big picture into
account and know when the policy apply and when they do not.
If you are interested in learning more about this or related
topics, check out my book: A
Guide to Clinical Decision Making
