If this forum is a podium, then allow me an opportunity to propose a concept that might improve the clinical practice of critical care transport (CCT) medicine. I suggest that providers, to include helicopter emergency medical services (HEMS), utilize modest yet practical resources to enhance their understanding of patient care. The approach I am referencing is the review of electronic health records (EHRs) after a patient has been safely handed off to the next provider. Do we not review the chart when we begin care of a patient, why not continue this same strategy after?
The purpose of this blog is to explore the benefits of after hand-off chart reviews and how this approach can enhance the clinical knowledge of a provider by reviewing the chart after what occurred when the patient was no longer under their care. Of course, there are some potential ethical and legal issues associated with this, but I believe the benefit if we can agree this practice is indeed ethical and legal, is an indispensable tool for learning that outweighs the implied consequences if any are present (Lawrence, 2017). Furthermore, I intend to provide a concise history of medicine as it applies to this theory and with any optimism, persuade you that this method is not only ethical but also applicable to improving our understanding of critical care medicine.
Learning from History
Clinical medicine has been practiced for eras and has grown exponentially since the “Father of Clinical Medicine” Hippocrates “wrote” his namesake Corpus so many generations ago (Tsiompanou & Marketos, 2013; Yapijakis, 2009). Much of what Hippocrates thought was fact turns out was based on flawed understanding, for example, bloodletting (Lagay, 2002; Greenstone, 2010; Dobken, 2018). Please do not judge me for this, but even the “Father of Medicine” made a lot of mistakes, yet he also made some significant contributions, like “do no harm”, keen observation of patient symptoms, and “the need to review evidence” (Tsiompanou & Marketos, 2013). That said, we learn from our mistakes, and I hope that what you conclude from this blog is that medicine is a necessary good, that requires a desire to learn from mistakes and seek the correct answer (Millwood, 2014).
However, without his mistakes, advancements in medicine might not have occurred, of course this is purely anecdotal, but likely. These advances can be beneficial when evidence-based research is used to ensure its reliability and just as important its validity; but, are we [CCT providers] fully benefitting from such advancements, even with innovative tools akin to point of care ultrasound (POCUS), tranexamic acid (TXA), and video laryngoscopes (VL) being introduced and implemented into our repertoire?
Clinical Chart Reviews to Broaden CCT Effectiveness
As providers we are tasked with a responsibility to continually improve our skills as well as our clinical understanding of patient care to ensure that the care we provide is of the best quality, but also, and in my opinion, precise at the time of the incident and fundamental to the core of medicine (Timmermans & Mauck, 2005). What I am suggesting is not only implementing technology into our clinical “tool bag,” but also following up with our patients and learning from what we did well as much as what we did not do well. This comes through experience, education, and the endless pursuit of looking for the answers to what is best for the patient.
Please allow me to elaborate. We all have read and used protocols handed down from medical direction, we have all sat in on countless hours of training and education to enhance our understanding of medicine which guides us, but this does not always provide a real-life application. So, what if, and I am stealing, rather paraphrasing this thought from a friend, we provide care to a patient we thought was beneficial, but our suspected diagnosis is wrong, and it turned out to be a differential diagnosis or worse? We treated the patient according to protocol, administered medications, and provided interventions we assumed were helping, but in the end, we made the wrong call. Under this paradigm, we would never know our management of said patient was improper, and the next time a patient presents with similar symptoms we treat him or her in the same fashion. Well, as you might ascertain, this leads us down a path of poorly practiced medicine, which hurts our profession but worse, our patients. So, what is the fix?
The Impact of Inquisitiveness
Over a thousand years after Hippocrates, a Flemish physician who is frequently referred to as the “Father of Anatomy”, was born (Bay & Bay, 2010). His name, Andreas Vesalius, he lived in modern-day Belgium during the Dark Ages of medicine (Nuland, 2008; Ambrose, 2014). What is more interesting about Vesalius and pertinent to this blog was his curiosity and desire to learn. Vesalius lived during a time when autopsies were illegal, and medicine was performed at a very rudimentary level compared to what we know today (Nuland, 2008). He changed this standard by searching for a better understanding of anatomy. His inquisitiveness led him to graveyards to exhume and steal bodies of the recently deceased (Nuland, 2008). According to Nuland (2008), he would then take the bodies to his lab and perform autopsies where he made intricate drawings of what he saw and used the knowledge he gained to pass on to others.
The point – Vesalius became a great anatomist and ultimately brought medicine out of the Dark Ages as a result of his curiosity. Most of his work is art and can be found in many medical literature books. However, primarily his work revolutionized medicine and is likely what modern surgeons use as a guide during surgical procedures. More specifically, his work applies to CCT and HEMS in the same manner, for example, finding landmarks during a finger thoracotomy. Additionally, it is curiosity that I believe is what we should focus on and how being curious, e.g., chart reviews will assist us in better understanding of critical care medicine. That said, medicine advanced as a result of his dedicated work and are we fortunate to have had someone so inquisitorial precede us.
Following-Up and Reinforcing Clinical Skills
Approximately a century after the untimely death of Vesalius was born a man by the name of Giovanni Morgagni, who became known as the “Founder of Modern Medicine” (Ventura, 2000). What is significant about Morgagni as it pertains to this blog or more importantly my endpoint, was his follow through and nearly perfect documentation of patient care from the moment he met the patient, until their deaths and through the autopsy (Nuland, 2008). This process allowed for Morgagni to presume a disease process during life and treat appropriately, but after the patient died, he was able to confirm his diagnosis or not, and that allowed for him to improve his clinical understanding of medicine and treat his patients more effectively while they lived.
This is why I suggest, and I am sure many of us already do, is to follow up on our patients once we have transported and safely handed care off to the next clinician who will be caring for the patient. This follow-up will help us, as providers, to better understand the disease process being treated and whether or not our interventions were accurate and beneficial to the patients’ outcome. For instance, imagine a patient you have picked up from a sending hospital and transported to the receiving hospital. You treat by administering medication and adjusting ventilator settings based on your understanding of what you believe to be the disease process. But, are not entirely sure because you lack the same tools a tertiary hospital has access to and cannot confirm what you did was correct until after reading the documentation completed by the receiving staff.
According to at least one article, following-up with our patients through the use of EHRs and chart reviews has the potential to make us more educated clinicians (Habboush, Hoyt, & Beidas, 2018). At least that is what I extrapolated that from the article. Regardless, there are many factors which will play into this concept; for example, was the receiving hospital a facility you have EHR access? If not, the framework is there, and we, as providers, should be diligent and seek out this information. It is possible that you may need to reach out to the physician or nurse taking care of the patient to obtain the information.
It may take effort but think about the work Hippocrates, Vesalius, and Morgagni put forth and how their drive led us to where we are today. I am not suggesting that we scour a patients chart and read their social work notes; this is likely an unethical practice (Lawrence, 2017). However, I feel confident in saying that if you have taken care of a patient, you should make every attempt at concluding your responsibility with a clear understanding of his or her pathophysiology and treatments administered during their in-hospital stay (after you have turned care over) it is (Habboush et al., 2018). That said, it is probably best that you are not reviewing his or her chart for months and years.
Summary and Conclusion
Throughout the ages, medicine has evolved, from Hippocrates mistakes, Vesalius’s curiosity, and Morgagni’s follow up with patients from life through death. History has a way of showing us what is right, what is not good, and what could be better. As a provider, I am well aware that I do not know everything, not even close. However, I yearn to learn – catchy, huh? Following up with patients after we have turned care over to the intensive care unit or emergency department should not be the end of our learning. It might be the last time we see this specific patient, but it may not be the last time we see the symptoms the patient was experiencing. Being inquisitive and following-up through the use of chart reviews is a critical component of enhancing our skills in the field.
In conclusion, history has shown us that we can be wrong and yet still learn from those mistakes; similar to Hippocrates theory of the four humors (Lagay, 2002). Curiosity is vital, and following up via EHRs is a privilege that has the potential, when used correctly, to make us as practitioners better clinicians (Schwinn, 2016). Not only can we better prepare ourselves for the next critical patient but also for the future of this ever-growing industry. It is essential for us to search for novel approaches to improve our skills and understanding of patient care. Utilizing an EHR is not complicated and provides us with a wealth of information that we can use to follow up with our patients after he or she has been treated.
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