Monday, November 25, 2013


     I used to tell nurses that one must do 'critical thinking ' One may ask as to what is difference between regular thinking and critical thinking? This was very important to me or to other doctors . We often get calls at night regarding patients . It is difficult to 'use' some one's eyes to know exactly what is going on . So it is very important to for a nurse to tell me exactly as to what is the problem and what is the possible diagnosis and what should be done . So I used to tell them on various cases and how to think and direct us to the right treatment . This then turned to be what is now called as SBAR. S stands for the 'situation ' B stands for background ( of the patient , like patient has history of congestive heart failure or GI bleed etc ),A stands for assessment (what is the impression of the nurse ) and lastly the R stands for the recommendation .(what is the nurse suggesting as the treatment ) . Now a days we have rapid response team or a nurse , who is a nurse from ICU and can give better assessment and advice . But what I want to do is consider this as a class to medical students.I feel that sometimes even many treating doctors . I am going to tell a story of a patient , that this will be obvious .

     I was called to see this young 50 years old female patient who was admitted with chest pain . She was nonsmoker and ha d not seen physician and was taking any medicines . She was not on birth control pills and was not sedentary . She had  a CT scan and it showed blood clot in the lungs . She was also anemic . She was admitted to hospital and the hospital doctor ordered 'blood thinner ' and gave her blood transfusion . I was also called to see patient . I did not not see any work up for the anemia or as to why this lady would get a blood clot in the lungs . When I asked her as to what was going on I realised that she was having heavy menstrual periods and that is why she had drop in her blood counts .I ordered the work up for both anemia and blood clot. I also called a hematologist , a blood specialist .He saw a patient and changed the blood thinner to a new one that does not need monitoring the blood thinner ( yes the one that is advertised on TV ) I talked to the patient next day , and then called the blood specialist . My concern was that with blood thinner on board, , she would bleed profusely with her next menses . So in my estimate , we needed  Gynecologist to check her out ( as the  pelvic ultrasound and it showed  enlarged uterus and big fibroid)  Using a long acting blood thinner without controlling the menstrual bleeding would not be a good idea .
   So this is critical thinking . Everybody knows that blood clots are treated with blood thinner and anemia needs blood transfusion and some work up . But to change the standard treatment to avoid complications that could occur withe the treatment . THIS IS CRITICAL THINKING .  .

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