Saturday, January 16, 2016
Mnemonics can be incredibly cool. When I was in medical school there was just too much stuff to remember and memory aids were so very helpful. Most specifically I refer to the vile and inappropriate one that helped me remember the cranial nerves which I remember to this day and will not share in print. In ancient times orators used memory palaces to memorize long speeches or poems, associating words with familiar and sometimes bizarre images. All this is to say that I have nothing against a good mnemonic. Lately though, as I have struggled to memorize a new acronym which is supposed to be good for me, I've been thinking about what makes a mnemonic good and what makes one annoyingly terrible.
The most irritating mnemonic in recent experience is probably the "H's and T's" from Advanced Cardiac Life Support (ACLS). When a person's heart has ceased to be able to sustain life or blood pressure, we use a memorized sequence of interventions to resuscitate them, the ACLS protocol. Ideally, we would all be fast enough and coolly competent and use our diagnostic skills and knowledge of treatment to rapidly and effectively help the patient recover in short order. The fact is that, for most of us, a cardiac arrest occurs rather infrequently and is associated with enough anxiety that, without a good solid script, shared with a treating team, we might just stand around and flap our hands and mumble. With the script we sometimes are able to restore a functional cardiac rhythm in time to keep from irrevocably damaging the brain. But if we try the usual maneuvers and nothing works, we are encouraged to think of the H's and T's. I have studied this for years and still I find that these letters do not help me much at all. That is because humans are not good at thinking of many things that start with the same letter. That's why the game Scattergories is actually challenging. A mnemonic has to be really good to work in a life and death situation.
In order to help me maybe remember the H's and T's again, here they are. If a person persists in being dead despite your best efforts they may have: hypoxia, hypovolemia, high hydrogen ion (acidosis), hypothermia, thrombosis of the coronary or pulmonary circulation, tamponade, tension pneumothorax or toxins (poisoning.) And don't you forget it!
The other annoying acronym is AIDET, a communication tool introduced by healthcare consultants the Studer group to help improve patient satisfaction. The Studer Group arose out of the experience of Quint Studer in using a business model to improve patient and employee satisfaction in a failing hospital. Many hospitals could use help and Studer techniques have become very well accepted by management in hospitals, though somewhat less enthusiastically by clinical staff, who right or wrong do not feel like they need a script in order to communicate. AIDET stands for Acknowlege, Introduce, Duration, Explanation and Thank You. As a grammar police person I resent the fact that these are different parts of speech. Two are verbs, two are nouns and the last one is two words that make up a sentence. If one does by some chance memorize the words the problem may reasonably arise that they don't actually tell one what to do. After attending a workshop one might learn that one is supposed to say, "Good morning, Mr. Qwerty. My name is Jkl;. I'll be working with you today in what I hope is your most awesome and joyful healthcare experience ever. In 15 minutes your anesthesiologist, Dr. Asdf will be in to assess you for your surgery scheduled for 2 PM today. You will not be able to eat prior to surgery but we will be happy to get you a late tray when you return. Thank you for allowing us to work with you today. We know you have many choices and we are happy you chose X hospital."
AIDET is not entirely bad. Maybe it's not mostly bad. But it is also not great. First the acronym/mnemonic. It doesn't work. That's one reason why hospitals have to get their employees to attend practice sessions to absorb it. And they do. I have failed to attend a practice session myself and, once I get back from Africa, I will likely need to do remedial work. A good mnemonic is ABC for airway, breathing, circulation, the recently replaced beginning of cardiopulmonary resuscitation (now CAB.) Or "righty tighty, lefty loosey" for opening a valve. Using AIDET to remember to recognize a patient, introduce oneself, explain what will happen and when and express gratitude of some sort is like grabbing for a cement life preserver. Maybe "who, what, when, where, why and hurray for you" or something goofy like that could work. The AIDET acronym is actually copywright protected so maybe that's why they push it--if you use it you have to pay Studer Group. Also the content and the concept is less than great. I accept that doctors and nurses often need to slow down and introduce themselves and explain what's going to happen, also to affirm the worth and dignity of the patient. But we need to do it in our own way, otherwise we lose our own dignity and will fail to notice what this patient needs at this particular moment. Patients will also start to notice that we are talking strangely.