My Dad has a saying …
“Can’t you see the potential for disaster?”My Dad
However annoying it was growing up, this saying has now turned into one of the easiest ways that I’ve learned how to think critically. Wondering about what could go wrong in a given scenario (where you’re always hoping for the best) is one way to anticipate problems.
Planning for and expecting the worst has helped me avoid significant issues throughout my career. In the emerge, we get much autonomy as to how we practice, and we have much leeway with medical directives. So, when someone comes in with EMS and their pressure is low, and you think to yourself, the easiest fix for this is a litre of fluid, I always stop before hanging said fluid and ask if the patient has any history of heart failure. If they are unsure, I look at their legs. I look at their legs to see if there’s rampant pitting edema, and maybe my patients are either not well enough to tell me that they’ve got a cardiac history or don’t remember that they’ve got a cardiac history.
Me asking those two questions can save the patient a horrible outcome. If I were to hang the 1000cc of fluid, I could correct the blood pressure, but I could also put the patient into pulmonary edema.
What’s the worst that could happen? The patient could go into respiratory failure and die.
How would I manage that complication before the patient stops breathing?
I would already have a close I have patient due to their blood pressure issue. With that, I would be taking vitals probably every 15 minutes. Within that time, you can usually audibly hear the crackles from the patient if they’re starting to become wet. At that point, I would auscultate the lungs and repeat vital signs to see if they need oxygen to see if they’re OK. For a moment, I step out and talk to the doctor about getting an order for Lasix.
The key to managing a complication is that the sooner you can anticipate problems, the sooner you can expect problems, the sooner you can deal with problems. Being able to predict what could go wrong and fix what could go wrong is allowing yourself to start to think critically.
The most common things where you can anticipate problems can be:
Blood pressure medications: make sure you do a blood pressure before giving the blood pressure medication. Why? Because the patient’s blood pressure is already low and you then happened to give a blood pressure medication, you will be dealing with a real issue.
Putting in a catheter. What could go wrong? If not done under sterile conditions could give the patient a UTI.
Think of it as “what it is that I’m about to do to the patient that could cause a worst-case scenario?” And then, “If the worst-case scenario happened – how would you anticipate fixing it, and are there things that could be done ahead of time to avoid it?”
Here’s an example to test your critical thinking.
Jenn is a nurse on a jam-packed medical floor. The patient is an elderly male who has been on the medical floor for months waiting for long-term care. He has been on diabetic medication, hypertension medication and vitamins for years. When Jenn walks into the room, the patient is disoriented, sweaty and doesn’t look very good. Knowing she’s busy, Jenn wants to get things organized as soon as possible because she’s got seven other patients to get meds done on. Jenn has already poured her medication for this patient before going into the room to assess them. Can’t you see the potential for disaster?