Ep 4 - Escalating Language of Concern with Dr. Katie Lin
What is Crisis Resource Management (CRM)?
It is a set of skills that helps improve team performance through communication, leadership, and interpersonal skills.
It can help build a common language and shortcuts so that even people that have not worked together before can work well together. Used well, it can improve efficiency.
While it is more formalized in other industries (aviation, military), it exists in medicine and has existed for some time, but is more practitioner-dependent.
Order of priorities when leading a resuscitation
Establish communication, your role, and the role of others (“I’m Dr. [X], I will be leading this resuscitation. Who else do I have in the room with me?”)
Try to build some rapport, if time permits
Gather information, starting with threats to life
Prioritize treatment, diagnosis, and transportation
Maintain situational awareness by continually seeking new information and revaluate the diagnoses, need for more information and revaluate the decisions that have been made and need to be made
Prioritize the patient’s safety but also remember your colleagues’ including transportation team
How to manage your stress response to perform optimally
Take a breath
“Slow is smooth, smooth is fast”
Use a systematic approach
Maintain control of the room (ask for quiet when necessary, ask those not immediately involved in the resus to step out, )
Summarize the situation and seek the input of others
The foot of the bed is often a good place for the resuscitation leader. They can see the monitor and all of the work being done, as well as the patient and their colleagues. It also helps reduce the urge to physically do tasks that might in the leader’s skillset, but that would take them away from leading the team.
Practicing CRM
Visualize / walkthrough / tabletop common life threatening scenarios (head injury, multisystem trauma, obstetrical hemorrhage, etc). Do the routinely to maintain proficiency and re-evaluate as real-life scenarios occur.
Situational awareness
“The continuous extraction of environmental information. The integration of this information with previous knowledge to form a coherent mental picture and the use of that picture in directing future perception and anticipating future events.”
In essence: noticing what is going on, processing it, and understanding its significance (what will likely happen in the future).
Avoiding fixation-induced loss of situational awareness
Continually scan the environment for cues (vital signs, patient picture, staff, look at the floor for blood, fluids etc)
Recognize that any complex or lengthy procedure will lead to task saturation and a loss of situational awareness (e.g. intubation, chest tube / central line insertion, vascular access etc)
Avoid doing those tasks or delegate the running of the resuscitation to someone else if you are the only provider that can complete that task
Continually seek input, challenge/prove assumptions, and summarize the situation to allow others’ to improve your situational awareness
Use closed-loop communication: expect it, and ask it of others
Buy time: summarize, have standard phrases (e.g. “IV, O2, monitors, I want a full set of vitals including glucose and temp”)
If you’ve lost SA, say so. “I’ve lost situational awareness due to the intubation. Who knows what’s going with X, Y, and Z?”
Summarizing for the team (shared mental model)
Where we’ve been
Where we are currently
Where we need to be
Priorities for making that happen
Telling the team the working diagnosis (e.g. respiratory failure, PE, etc) can help them access their own mental schema for that and they can watch for your blind spots and anticipate things that may be otherwise forgotten. It also makes explicit the idea that what is going on is a life threatening emergency and reduces confusion.
Say “critical finding” to alert the team to issues
When to summarize:
At handover (establishes roles and sets priorities)
Before and after a critical procedure (e.g. intubation, chest tube insertion)
A critical change in the patient’s condition
Tips for leading resuscitations with fewer resources
Fewer hands increases the importance of prioritizing and not overloading your colleagues
‘Chunking’: Make a list of medications and batch them in three’s (these 3 first, then these 3, etc.)
Use whiteboards / paper to hold the big picture, as things may not move as fast
Manage your workload: Give the list and say “please let me know as these medications are given” (then you can focus elsewhere
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance: A handbook for all acute care health professionals. Edited by Peter G. Brindley and Pierre Cardinal
Dr. Lin’s tips on building rapport and interpersonal dynamics: (51 mins)
Start from a place of mutual respect and professionalism
Who is in the room / on the call? What is their role?
Disagreements happen, but we must be able to disagree in a professional manner
Stay grounded and help others to stay grounded. (e.g. Pause, take a breath, remind everyone “this is a recorded call”)
Validate feelings of frustration: “This is a challenging situation”
Hit the reset button: “I think we’ve gotten off to the wrong start. Can we pause and reset? Can we start again?”
Acknowledge the person’s expertise and find common ground: “I’m asking for your help right now because I’m really worried about this patient. I would really appreciate your help because I don’t know what to do next. I think we can agree on X, Y, and Z.”
Announce: “Critical finding [x]”
Assertiveness models
The ‘I notice’ model
I notice [x finding] “I notice that the oxygen saturation is starting to drop. Do you want to do anything about that?”
I wonder [why the provider is doing something]. “I wonder if we should apply a non-rebreather mask at 15L/min?”
I worry [express specific concern] “I’m worried about the hypoxia.”
This is an emergency (I’m taking over)
The PACE model
Probe: “Why is [x] being done?”
Alert: [X finding]
Challenge: “We need to do [Y[“
Emergency: “This is an emergency” (I’m taking over)
Other resources
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance: A handbook for all acute care health professionals. Edited by Peter G. Brindley and Pierre Cardinal
Random recommendations
Katie: The Anthropocene Review by John Green for “a moment of thought-provoking calm”
Adam: Exit the Game
Amir: 99% Invisible podcast