Douglas Drachman, MD: Learning Through Cardiovascular Crises

March 18, 2019
Kevin Kunzmann

Why every care provider must be able to prepare for and commit to an "emergency protocol" in the face of adversity.

There’s always something to learn from the most burdening moments of providing care that could make it potentially less burdensome—and more successful—the next time it happens. For cardiologists working in trauma care, open communication and step-by-step procedure adherence could make a world of difference.

In an interview with MD Magazine® while at the American College of Cardiology (ACC) 2019 Annual Scientific Sessions in New Orleans, LA, Douglas Drachman, MD, director of Education at Massachusetts General Hospital, recalled discussion at a session focused on managing emotional experiences in catheter laboratory work. The anecdotes from that session feed into a pattern of proven methods cardiologists could follow to improve their crisis management.

MD Mag: What can a cardiovascular care team learn from one another in trauma care and crisis management?

Drachman: I think that's a great way to look at it, because it really is crisis management, and I think that one has to reflect on when one first experiences a circumstance like this is, first recognize it immediately, then identify the protocol that you wish to engage so as not to make matters worse.

It was fascinating, because for example, the first presentation was focused on the development of a coronary artery dissection. And I think the natural reflex when one sees something that is happening in a procedure that is an adverse event, one wants to characterize it and say, “What's going on? What do I need to do?” And one of the worst things you can do when there's a

coronary dissection is continue to take pictures of that artery by injecting contrast into the vessel, because the mere act of injecting the contrast in the first place may have been what caused the dissection, and if you keep on doing it you will just propagate that dissection to make it worse, and lead to a further adverse outcome for the patient.

So what we have to do—this is a very specific example, but to abstract that learning—is to say: rather than keep on doing, or looking, or checking, or testing, we have to implement immediately our emergency protocol. And that likely is first to recognize it, and to announce that this is going on to all the members of the cardiovascular team, number 1.

Number 2 is to share the experience of all members of the team in real-time—to say, “Here's what we need to do.” And often, it takes fast action to help to salvage what's going on, or to protect from things getting any worse, or to stabilize the patient and to implement really in parallel rather than in series. So everybody's kind of working towards the same cause and same outcome: our emergency procedures to help.

Then, at the end—once hopefully the patient has been stabilized, at least with a temporary method—to think about the more permanent solution. For example: in a case of a perforation, it may be to seal that part of the artery by immediately inflating a an angioplasty balloon at the site that is perforated. Take a moment to think about, “What equipment do we have in the lab? What else can we do? What do we want to do with the individual’s systemic anticoagulation program, and to take stock of how to resuscitate the patient in that circumstance?”

And then, to move forward with a more durable and permanent solution. Finally, after the fact, to debrief—and this involves all members of the cardiovascular team, to share from their wisdom often. At most institutions, there will be a morbidity and mortality conference where the shared reflections of all operators and all clinicians, all members of the cardiovascular team, would be derived at that time. Then—to develop a plan for how to prevent these events from occurring in the future, and how to treat them when they do occur.