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Aviate, Navigate, Communicate


Mike is a big guy, more than 300 pounds (a lot of it muscle), in his 40s, no meds, no allergies, no past medical history. For the past week he has been experiencing increasing pain in his hips, knees and feet. His knees and feet are swollen. Yesterday, he was in extreme pain and unable to bear weight. The pain meds he was prescribed don’t put a dent in the pain. By the time we get to his house, he’s in agony with tears streaking his cheek. This is no complainer; this guy is hurting.

He can’t even walk to the cot. There are only two of us on the call, so it takes quite a bit of sweat, grunting and careful planning to get him into the rig. It’s about a 10-minute ride to the hospital. We do an assessment to rule out a treatable etiology and conclude we have no idea what this is. Gout? No history. Injury? No history. I’m no Dr. House, but my only far-fetched guess is that he reported being treated for strep throat the day before this began—could the infection have migrated? Oh well, above my pay grade.

Anyway, we need to give this guy some relief. Our service uses either IV or nasal fentanyl. I try two IVs. It’s like sticking a needle in a beach ball … once you get in, all the structures you think you palpated through the skin disappear, and you feel like you’re waving your catheter around in thin air. So, we go to plan B: the nasal route. It takes a total of 200 mcg to start relieving the pain.

Like I said, it was about a 10-minute ride to the hospital. So after assessment, two IV attempts and four squirts of fentanyl, guess what? Not much time left. Get to the hospital, turn over patient care, get a face sheet, go to the report room, tear off the piece of tape from your pant leg with your scribbled notes and write up the report. No big deal, right?

But this is the age of electronic patient care reporting; the newer, better, more efficient way to chart. It’s also the age of balancing how much I ignore my patient and my job in order to get as much information into that electronic slab so I can keep my charting time under the arbitrary limit imposed by management. Get the information from the patient at the hospital? No time. Wait for the face sheet? No time. So what that means is during every call I spend at least as much time charting as I do engaging in patient care—let alone having a calming conversation with the patient in the back of the rig on the way to the hospital, having time for additional assessments or treatments or holding the patient’s hand (I need it for typing.)

I’ve heard the exact same complaint from emergency department doc friends. The computer stands between the caregiver and the patient, literally, symbolically and functionally. The focus of the interaction is diverted from the patient to the computer.

Don’t get me wrong, I’m aware of all the good things these machines do: eliminate illegibility, provide a standard format, permit efficient distribution of information, provide statistical data. But there’s a steep price to pay for these advantages, and we pay it in the coin of less human interaction, compassion, and patient care.

Pilots have a simple, brilliant rule: aviate, navigate, communicate … in that order. Always. It’s like airway, breathing, circulation in medicine. You never go to the next task without ensuring the preceding task is complete, because without the preceding task, the subsequent task is moot. If you don’t aviate, you crash; if you don’t navigate, you run into stuff. Years ago when I was taking my flight instructor check ride, I was turning from the base to final leg of my approach. That’s a busy time, requiring the pilot to watch for traffic and configure the airplane for landing. While doing all that, I was also announcing my intentions on the radio with the handheld microphone, which required the use of my right hand.

“Why are you talking when you should be doing?” the examiner pilot asked. “Configure the airplane, establish your glide path, and only then, when everything is done, pick up the microphone.”

Aviate, navigate, communicate.

That’s what I always tell myself when I’m torn between the patient and the computer. Get them where they’re going safely, then document. It doesn’t solve all of the problems created by the electronic age, but it’s the best I’ve come up with so far. I hope management will understand.




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