Typically if I engage someone with a particular question, it’s because I perceive they have a knowledge base or experiences that I can learn from. My brain often gets frustrated when someone answers a specific question with an unsatisfying and vague response. This happens ALL the time on panels at medical conferences and on social media.These often include.. - Just look at the patient - Do what’s best for the patient- Look at the patient not the monitor- Depends In reality, we are making specific decisions in situations on a daily basis. As much as we pretend we need an entire CMP, ABG, vital signs, blood type, and medical history in order to make a decision, we commonly begin making decisions with very limited information. Walking into a room and seeing a septic patient bucking the vent and hypotensive has (should have) an immediate decision momentum that surfaces.So why be vague? When we are vague and paint with a broad brush, we reduce vulnerability and protect our reputation. When interviewing someone, you will often hear Scott Weingart say: “I want to put your feet to the fire on this, and nail you down to an answer.” I love this. Hearing actual real world answers based off initial gestalt helps me compare my clinician decisions with others. For example, suggest I ask you “How are you determining when to switch to or augment nitro with analgesics?”Vague Response: “It really depends on the patient.”Descriptive Answer: I typically start with a nitro drip at 60-80mcg/min and aim to keep my MAPS between 90 and 100 to optimize coronary perfusion. If patient remains in pain, I will give 50mcg aliquots of fentanyl. I know that coronary perfusion pressure is typically like 50 mmHg, and I know I have to subtract the bag of pressure within the ventricles from my diastolic pressure to calculate my coronary perfusion pressure. So I probably don’t want my diastolic below 50. Buuttttt my auto-cuff bp uses an oscillometric technique for capturing blood pressures, so a MAP of 90-100 will more than likely maintain that cPP.
Is this answer the best possible answer?! Who knows? But this is what I honestly do, and how I frame my thinking. There is no mortality benefit or strong evidence for nitro and I’m sure someone smarter than me can tell me a different way of doing it. However, if I never actually tell people what I do, how will I know?
So next time someone asks you what you would do, tell them. Be transparent and eager to adjust Bayesian priors.
Original author: Tyler Christifulli
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