“If I go to the doctor, and if he’s not ready, I leave. And that’s because of mise-en-place.”
– Andre Soltner, Dean, International Culinary Center, New York
I was finishing up breakfast on a weekend shift not long ago when my shift captain had texted me to head back over to the hospital. We had a critical care level transfer that was combative and might need some significant work to get ready to transfer from our critical access hospital to the community hospital about an hour and a half away. I was less than pleased leaving my “San Juan” benedict… (Good green chili makes the world go around.)
Coming into the ED like I generally do, via the ambulance bay, I looked in rooms 5 and 6. These rooms are typically where the sick patients go, or the ones who need the most eyes on, as it is right across from the nursing station. The patient sitting in room 6 was calm, resting, and had a visitor sitting next to him. I was almost lured into the fact that I was either being pranked again or given insufficient information.
Of course, this wasn’t the case as I heard one of the medics on my team raise his voice and found him and three others in near fisticuffs with a patient who looked in his mid-20’s, poorly kept, yelling in full sentences that were totally incongruent with any linear process going on, who was flushed and sweating. At this point, I knew I needed a solid plan on patient care, collaboration with the ED team and my team, and that I wasn’t going to have a peaceful process digesting my breakfast. The rest of my team was working on getting the patient on our litter, restrained, IV’s re-established, and all that good stuff, so I spoke to the ED physician to get some intel as to what was going on.
The patient is a 28-year-old male, brought in by PD. (Hats off to that officer if this guy was even 20 percent as combative as he was currently.) The patient was found wandering around the grocery store grounds and the hospital campus as they are adjacent to each other. ED doctor says the patient was initially calm ‘enough’; they got a line in him, gave him 25 of Benadryl, 5 of Droperidol, and 5 of Ativan prior to EMS getting involved. He’s got a high Tylenol level, is believed to have ingested an entire bottle of Zoloft that he just got filled at the grocery store and is also positive for methamphetamine and alcohol. He has a history of prior admission and being on a psych hold for being suicidal after walking in on his roommate dead from an overdose.
Oriented to place.
HR: 124 Regular
Temp: 99 tympanic
Tylenol level of over 100 mcg/ml
BGL: Within normal limits
Given that information and speaking to the team in the ED, the working diagnosis I was going with for this IFT included:
- Altered Mental Status from meth, ETOH, and other possible pharmaceuticals.
- A combative, uncooperative patient is who is altered, needing restraints, monitoring, and airway protection.
- A generic concept of poly-pharm overdose.
- Serotonin Syndrome
Because of all these issues going on, and how extremely combative this patient was, even after the ED had given him chemical restraints, I had concerns this patient was going to be complicated and easily become a task saturating transfer, both physically and mentally, and that a team-driven plan that everyone understood and agreed on was needed to make this happen.
“Resources are precious. Space is precious. Your self-respect and the respect of others are precious. Use them wisely. Isn’t that a philosophy for our time?”- Dan Charnas, NPR (https://www.npr.org/sections/thesalt/2014/08/11/338850091/for-a-more-ordered-life-organize-like-a-chef)
Yes. I am going to talk about a mental model again. I like this one, though, and I think it’s way more rooted in a tangible reality than some other ones. Not too long ago, I listened to a podcast by the Art of Manliness on Mise en Place. They were interviewing Dan Charnas, who recently wrote a book on the topic, which I got, and I think it is well worth the read. It goes in-depth on prioritizing tasks and managing an office balanced with being operational in a kitchen, which I think greatly correlates to what we do in pre-hospital care. (https://www.artofmanliness.com/articles/mise-en-place-how-chefs-organize/).
It comes from professional chefs and cooking in fast-paced, no room for error commercial kitchens. The literal translation is ‘everything in its place.’ And for calls where we have a little time to prepare things, I think the concept of Mise en Place is a great way to break things down and can significantly help move the grey world that we work in into some more defined and thoughtful pathways should the situation continue to be dynamic. The writing on this topic hits home for me in terms of planning and mastering the dynamic combination of science and art that we do in medicine, much like what happens in a kitchen. “Mise En Place…means far more than simply assembling all the ingredients, pots and pans, plates, and serving pieces needed for a particular period. Mise en place is also a state of mind. Someone who has truly grasped the concept is able to keep many tasks in mind simultaneously, weighing and assigning each its proper value and priority. This assures that the chef has anticipated and prepared for every situation that could logically occur during a service period. – The New Professional Chef (https://www.reluctantgourmet.com/mise-en-place/). I feel like that quote is spot on in terms of patient care during any transport, let alone something along the lines of a high-level ALS/Critical Care IFT. I created this highly detailed graphic to help break down my thought process; while I was getting ready to prepare for the transport of this patient, my team was calming down and securing to our litter for safe transport:
I get that not every call, let alone every IFT, enables you to do this, but this is the operational mindset that I embrace when I get ready for these types of tough calls. I also verbally review this with my partners and the sending team. This allows them to address any bias I had during my planning, close any gaps that remain, and keep everyone on the same page. I have also found it successful if the nurse/MD giving report to the receiving facility includes the EMS care plan. It dramatically reduces surprises, which is something everyone in our profession can appreciate.
By the time I had gotten the report, made, and discussed some plans of action with the ED team, my co-workers had done a superb job with the patient. They got two more lines, hung the bolus of acetylcysteine, applied soft restraints and the cot seat belts in a safe manner for the patient to minimize any harm to him and protect his airway since he was still moving around, and covered with the appropriate amount of blankets as he was overheating. However, it’s still cold out here in the Rockies. The patient did fine en route; I did end up starting a Versed drip. He became restless in the back of the rig (he went from a calm -2 on the Richmond Agitation and Sedation Score to about a 2.), and I further sedated him with another regime of Inapsine as we got closer to the receiving facility, knowing that my patient was going to have more stimulation.
Our Mise en Placed worked well. I brought another provider with me, we pre-mixed a versed drip, brought our second Pelican box of narcotics since I used all of the Versed we carried mixing the drip, brought extra channels on the pump, and had all our doses ready in case we needed to RSI him. My partner and I in the back were all on board, and we even talked about the best places to stop if we needed to pull over. We delivered a patient who had various levels of combativeness, along with other processes going on that could have led to the need for aggressive management, and I contribute a lot of that because we put everything in its place, from intellectual concepts about patient care to operational and logistical needs.