For me, the most important image from Greg McKeown’s book “Essentialism” is a circle with “energy” at its center. In one circle, energy is expended in several directions. No net progress is made when adding all these vectors. In a second circle, all the effort vectors are aligned. Adding these vectors takes you somewhere. Your goals determine in which direction you point your effort.
Remember that Oxygen Delivery is composed of two parts:
What is Shock?
[Oxygen Delivery] = [Oxygen Content] [Cardiac Output]
In the first video, let’s go over problems with that second part: cardiac output.
How can cardiac output go wrong? All of these can lead to decreased cardiac output.
- Cardiac: problems with the PUMP. The heart won’t push blood forward.
- Blood vessels: problems with the PIPES. The blood vessels are causing either obstruction to flow or are so massively dilated that blood just pools within or leaks out.
- Fluid volume: problems with the TANK. There’s not enough fluid to pump around.
The commonly taught categories of causes of cardiogenic, obstructive, distributive and hypovolemic fit into the above three physiologic groups.
How do you diagnose shock?
You can recognize shock by hypoperfusion of organ systems. So you’ll find measured blood pressure is low. Also, decreased blood flow to the
- kidneys leads to decreased urine output
- brain leads to altered mental status
- skin leads to cyanosis.
Remember that H&P are the best diagnostic tools we have. So search for potential signs and symptoms for diseases of the pump, pipes or tank. Ultrasound (the RUSH protocol) is very helpful as well. Treatment depends on identifying the cause.
How do you treat shock?
Treatment depends on the cause of hypoperfusion.
- PUMP problem? Maybe you need an inotrope or other cardiac support
- TANK problem? Then fill up the tank. Use whatever fluid you need, but remember crystalloid doesn’t carry oxygen.
- PIPE problem? Then, assuming you have a full tank, you need a pressor.
I rarely do the the weekly review in the GTD process, but can see its importance to get a handle on the upcoming week. Here’s a process I heard on David Allen’s podcast.
- Collect Loose Paper and Materials. Find all papers, receipts and other things and put them all in one place. Actually, you should be doing that all week.
- Empty your head. The other place clutter collects is in your mental to-do list. Except that requires constant attention to keep it from vanishing until it is written down.
Process and Organize
- Get “In to Zero.” Completely process all outstanding paper materials, notes, voicemails, emails, everything. To process means whenever you come in contact with the item, you do one of four things:
- Do (especially if it takes less than 2 minutes to complete)
- Defer (put in a to-do list)
- Review Action lists. Mark off all completed actions and review for any further action steps needed to be done.
- Review the past week’s calendar. There may be remaining action items, reference data or other items that you need to do something about or archive. I need to send out those meeting minutes from last week. Let me put that in my Inbox To Do.
- Review the upcoming week’s calendar. Look at both the week and month ahead and capture any actions looking at this may trigger. I have a report due in 2 weeks. I should email people to get the info I need. Let me put that report and email reminder in my to do list.
- Review waiting for list. Are there any items that require nudging of people to get things done?
- Review Project Lists. Evaluate the projects, goals and outcomes, one-by-one, ensuring that there is at least one next-action on each.
- Review any relevant checklists. use this as a trigger for any new actions.
- Review the Someday/Maybe list. There may be some projects that can now be active. Anything that is no longer interesting can be deleted.
- Be creative and courageous. Any new hare-brained, thought-provoking, risk-taking ideas to add to the system?
It may be helpful to do this in a creative spot, like Starbucks. Reward yourself with a coffee so that this can become an enjoyable habit.
For the inevitable moment when the medical record eats all my macros, I’m backing them up here. Also, if anyone finds them useful, feel free to steal them. I stole them from elsewhere.
Continue reading “Mental Status Exam”
Here’s two short videos giving an overview of upper and lower GI bleeds.
I start every video with “Now let’s talk about…” Pretty annoying. I need a catch phrase.