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Friday, July 20, 2012

Have guidelines replaced critical thinking?

I think guidelines and order sets are good in a way, yet more often than not I think they are used as a crutch, or as an excuse to be lazy.  I honestly and truly believe guidelines and order sets have replaced critical thinking.

Guidelines are good in that they help "guide" our thought decision process.  They help us with the critical thinking process given an individual set of circumstances.

A good example here is Basic Life Support (BLS) and Advanced Cardiovasular Life Support (ACLS).  Given a specific emergency situation, and given specific medical training, these programs help people decide what to do in various emergency situations.

That sounds good, yet it's not always good.  For instance, most BLS programs say you should give breaths after so many chest compressions for people in presumed cardiac arrest.  Yet some people get so  intent on making sure they give breaths that they become overwhelmed and do everything wrong.

In this way, the layman's attempt to do BLS right replaces common sense, which would dictate that if you do chest compressions correct you shouldn't have to give breaths.  Common sense also dictates that if you give mouth to mouth breaths you are giving that person less oxygen than is in room air, which is not enough to sustain life.

Common sense would say you treat the patient not the order set, guideline or "ALGORITHM."  Yet there are a ton of nurses, respiratory therapists and DOCTORS who's main focus is on order sets, guidelines and algorithms, and they focus so hard on following these things they don't think.

Those who suffer are the patients, who get less than adequate care.  I can give example of up the ying yang, starting with doctors who order Albuterol on every patient because they were taught in medical school that this drug cures all annoying lung sounds and lung diseases.  Yet an accurate assessment of the patient, with a dose of critical thinking, would reveal that the patient actually needed lasix.

The best example I can think of was once a patient was inadequately breathing yet was still awake.  ACLS guidelines say if you have to put a mask over a patients face so you can give breaths with an AMBU bag you should have a second person hold the mask firmly over the patient's face and have a second person give the breaths.

Yet I was doing both on my own, and the patients sat was 99 percent.  The patient was getting adequate breaths.  Yet the doctor insisted I take my hands off the mask and she held it so tight that air was squeaking out the edges of the mask.  The patient was fighting.  Then all of a sudden the patient's sats were in the 70s and the doctor panicked.  She said it was my fault because I didn't follow the ACLS guidelines.

Yet I disagreed.  I told her it was her reluctance to do critical thinking that caused that patient's sats to suddenly drop, and it was for that reason this patient needlessly died of asphyxia.  She died because she was so intent on following the ACLS guidelines that she failed to think.  She killed the patient not because she had bad intentions, but because she was taught to follow the guidelines.

What we must realize is that guidelines, order sets and algorithms are good, yet they are just that -- guides. Guidelines must not replace the critical thought process.


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