O2 ACS and Unlearning

by Darin Abbey

THE CASE
There you are in your clinical arena when a patient presents with chest pain. Aspirin is administered, labs are drawn and an ECG is obtained which shows no time sensitive findings. Bedside monitoring is established, the patients vitals are all within normal ranges and after a targeted history and physical exam, the wait for the troponin begins.

THE CHALLENGE
A colleague notices that the patient is breathing room air and expresses concern that the patient is not receiving oxygen. As a savvy clinician you know that in the recent 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes it is suggested that “supplemental oxygen should be administered to patients with NSTE-ACS with arterial oxygen saturation less than 90%, respiratory distress, or other high-risk features of hypoxemia.” Following these guidelines, oxygen is not administered.

Further you know that if this patient encounter evolves into a STEMI the administration of oxygen may indeed cause harm.

LEARNING AND UNLEARNING
Like your colleague you too remember learning that oxygen met all comers with chest pain. Yet somehow along the way your practice changed. You learned, and you later unlearned. Perhaps this process was subtle and without angst or perhaps it was sudden and stressful. With the increasing pace of knowledge transfer within our industry, as quoted by Rushmore and Davies, Solovy notes that “… climbing the learning curve is only half the process… the other half is the unlearning curve.”

As a part of one’s commitment to being both an evidence-based clinician and a mind-full change agent, it is valuable to consider both of these processes. As we learn how to make the transition from old information to new, we may find both obstacles and opportunities for learning and practice change.

CONSIDERATIONS
How might you engage your colleague in a conversation about the changing role of oxygen in chest pain patients? Have you given much consideration to the dynamic process of learning and unlearning in healthcare? How might mastery of unlearning increase ones ability to learn?

 

 

Suggested reading and to learn more:

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

http://circ.ahajournals.org/content/130/25/e344

Avoid the oxygen reflex

http://www.scancrit.com/2014/11/26/avoid-oxygen/

The (Un)Learning Process

http://shortcoatsinem.blogspot.ca/2014/02/the-unlearning-process.html

Unlearning in Healthcare by Rushmore and Davies

http://qualitysafety.bmj.com/content/13/suppl_2/ii10.full.pdf+html

SGEM#49: Five Stages of Evidence Based Medicine Grief

http://thesgem.com/2013/10/sgem49-five-stages-of-ebm-grief/

 

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