mybetterdoctor

Dear Riverton team,

Happy Wednesday! I have been thinking about the types of interventions I’ve seen have greatest impact since I became a doctor. As my view of medicine has broadened, I am seeing similar lessons across other specialties and I thought it might be helpful to share some reflections and ask your thoughts about how you’ve seen your areas evolve and where you’ve seen the greatest impact.

What makes the difference in medicine?

Fiddling with knobs on a ventilator, rapid response teams, and sepsis: a play in three acts

Act I. Fiddling with knobs on a ventilator

As a pulmonary critical care fellow, I always thought of the landmark ARDS study published in 2000 as the epitome of what can be achieved.  In this study, managing patients with acute respiratory distress syndrome, people who have very high mortality and can linger for days or weeks intubated in the intensive care unit, could live longer by receiving lower tidal volumes via the ventilator.  It was a remarkable observation.  The list of interventions which were tried, and failed, to improve the outcomes for patients with ARDS is long. But this strategy of consistently adhering to low tidal volumes improved survival. 

In the decades since, we have learned a lot about protocols and institutional culture, innovation dissemination, and local context. We all think we’re doing the right thing, but might not be.  Being really, really, really smart about ventilators may not be all that important, compared to having a system, a team, and a culture of team work and safety that adheres to these protocols in order to be able to ensure we are consistently treating our patients with this life saving ventilator strategy, and appropriately liberating them from the ventilator.

How can it be, and yet it most definitely IS, that one of the most important interventions for patients with ARDS is simply assessment, reassessment, and small adjustments?  Hardly anything more than “fiddling with knobs on the ventilator” is what helps us save lives!

1. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome | NEJM https://www.nejm.org/doi/full/10.1056/NEJM200005043421801
2. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation – PubMed (nih.gov) https://pubmed.ncbi.nlm.nih.gov/14726421/