You Don’t Have to Know Everything
I picked up a new book the other day called The Personal MBA by Josh Kaufman. Within the first few pages, I got hit with a couple of fantastic gems that translate so well to our world. I will be adapting some of Josh’s concepts to us so that you can walk away with some of the same motivation and inspiration that I did.
You Don’t Need to Know It All
This one is an easy principle to violate. There is so much that we have to know in the world of resuscitation and transport operations that we can “over-train” and overindulge in the pursuit of trying to remember every trivial piece of information available. Kaufman goes on to elaborate on something that I believe is key and essential. Whereas every trivial bit of information has a place, we are better served by understanding (very deeply) sets of core concepts from which we can operate. The terrific thing about this is that, in our world, the core concepts are already defined for us and pretty concrete.
The core concept of oxygen delivery forms the foundation of all of my thought processes when approaching a sick patient. Do they have oxygen in their arterial system? This leads you to evaluate airway control and begin to develop a strategy for oxygenating the patient. Is the patient losing (through hemorrhage) their ability to carry that oxygen to the tissues, or do they have a problem (thinking acidosis) with how well or poorly that oxygen is loaded/offloaded? Finally, the last thing to consider is a problem with cardiac output, but it is the most important part. We evaluate the patient for heart rate issues and then focus on augmenting stroke volume with fluids and vasopressors as needed.
Core concepts of mechanical ventilation are key and essential to safely managing the oxygenation and ventilation of intubated patients. At the core is the simple arithmetic of minute ventilation: VE = Vt x RR. If poorly controlled, the two elements of volume (Vt) and rate (RR) can be detrimental to the patient. Modes of ventilation and their evidentiary support mean nothing if the core concepts are poorly applied.
A quote from the book by Jack Welch highlights the simplicity of business and tickles the core of what I am getting at here:
“People always overestimate how complex business is.”
-Jack Welch
I see this time and again out in the world of critical care from both the operational side of things and the educational. We overestimate how complex the human machine is to manage. Yet, we can become enamored and bogged down in the methods we use to address these problems, which, most of the time, are not so simple to fix. We are inundated with new tools begging for the evidentiary support to be “THE” solution to a particular problem. Which vasopressor works better in the setting of XYZ type of shock? Which ventilator or mode of ventilation is better for ARDS? Now, in the pursuit of answering these questions and gathering evidence, we can advance our understanding of the core concepts, but the unchanging core concepts are still there underneath all of the studies and debates.
If the core concepts are so concrete and well defined, after all, it is science, why do we not all just think simply about the problems and implement the simple solutions? I believe that this is where the human factor begins to influence things. It is not that the concepts are difficult to understand and apply, it is our conceptualization and the mental models we have built around those concepts that hamper performance. Accurate and simple mental models are the key building blocks for the scaffolds of concepts that we use on a daily basis to take care of patients.
By filling in the spaces between the scaffolds with excellent evidence-based interventions, we have an excellent framework for approaching the critically ill.