Post 2 — The Danger of "It Should Work" CLINICAL REASONING · PREVENTABLE COMPLICATIONS

 When Complexity Meets the Standardized Box

An educational series about individualized care, medical complexity, system design, and the human life at the center.

Post 2 — The Danger of "It Should Work"

CLINICAL REASONING · PREVENTABLE COMPLICATIONS

“It should work.”

Four words that can become dangerous when the person receiving care has extraordinary medical complexity.

My son Alex uses a diaphragm pacer as his primary respiratory support, with a ventilator providing additional assistance.

He also requires continuous heated humidification.

For many individuals using a ventilator, a heat-and-moisture exchange filter (HME) is a practical alternative to an active humidifier during mobility.

We tried that approach.

It did not work for Alex.

His secretions became extremely dry, and he experienced severe airway plugging.

The standard solution was not a safe solution for him.

Consider another example.

Alex’s implanted diaphragm-pacing wires travel beneath his skin and emerge at an external connection site.

When that area develops redness, drainage, or other changes, it cannot automatically be treated like an ordinary skin problem.

The wires are connected to a life-sustaining device.

An intervention that seems routine could introduce risks if the person providing care does not understand the underlying equipment and anatomy.

We coordinate with the specialized diaphragm-pacing team when problems arise.

Why?

Because knowing how to perform a task is not the same as understanding the system the task affects.

A person can follow an established procedure perfectly and still create harm if the procedure is inappropriate for that individual.

Good care requires more than knowing what usually works.

It requires knowing when to question whether it will work.

Sometimes preventing a crisis begins with refusing to make an assumption.

Don’t wait to unleash a beast that could have been prevented.

Investigate first.

Understand the individual.

Then act.

#PatientSafety #DiaphragmPacing #RespiratoryCare #ComplexCare #ClinicalCompetency #IndividualizedMedicine #BeyondTheProtocol