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:
    1. At handover (establishes roles and sets priorities)
    2. Before and after a critical procedure (e.g. intubation, chest tube insertion)
    3. 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
    1. I notice [x finding] “I notice that the oxygen saturation is starting to drop. Do you want to do anything about that?”
    2. I wonder [why the provider is doing something]. “I wonder if we should apply a non-rebreather mask at 15L/min?”
    3. I worry [express specific concern] “I’m worried about the hypoxia.”
    4. This is an emergency (I’m taking over)
  • The PACE model
    1. Probe: “Why is [x] being done?”
    2. Alert: [X finding]
    3. Challenge: “We need to do [Y[“
    4. Emergency: “This is an emergency” (I’m taking over)

Other resources

1. 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
2. EMsimCases.com 

Random recommendations

1. Katie: The Anthropocene Review by John Green for “a moment of thought-provoking calm”
2. Adam: Exit the Game
3. Amir: 99% Invisible podcast

Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.

Transcript

SPEAKER_00 0:04

But I think that the challenge when it comes to CRM in medicine is that in many other fields, CRM is baked into the practice of those professions. And so people have a certain set standard, but we don't have those same standards in medicine. We're kind of just thrown into it, and you figure it out and you sink or swim to a large extent, but obviously with graded responsibility. But it's not necessarily a formalized curriculum that we go through when we're training. And so we kind of pick it up as we go.

SPEAKER_01 0:37

Hello, you're listening to the Medical Safety Podcast. I'm Amir Hammond. And I'm Adam Shahada. We're physicians in Canada and talking about how to improve our healthcare system by integrating human factors into system safety, including medical incident investigation and proactive safety measures. In the previous episode, we talked to Captain Mike Schuster about the origins of crew research management in aviation. In today's episode, we will discuss medicine's adaptation of CRM principles called crisis research management with Dr. Katie Lynn, who will discuss the escalation of language of concern during resuscitation.

Dr. Katie Lin

SPEAKER_01 1:08

Dr. Katie Lynn is an associate professor of emergency medicine and clinical neurosciences at the University of Calgary. She completed her residency training and stroke fellowship in Calgary alongside a parallel master's of public health through Harvard. She's a stroke attendant with the Calgary Stroke Program and a flight transport physician with SARS Air Ambulance in Alberta. She's also, luckily for us, the deputy director of podcasts at EM Cases.

SPEAKER_00 1:32

Thanks so much for having me on the podcast today, gentlemen. I'm all of two weeks into my new deputy director role with EM Cases. So excited to be here with you as well.

SPEAKER_02 1:41

We're very lucky to have you. Thanks so much for coming on as we work out how to get this podcast off the ground. If we can get started with just some general questions, do you mind telling us how you got started in medicine?

SPEAKER_00 1:52

Absolutely. I took a bit of a roundabout way to medicine. I didn't necessarily think about medicine early on, but when I was younger, my grandmother actually suffered a stroke when I was still in elementary school. And at the time, both of my parents were working double jobs. My dad was still finishing his PhD, and we had very limited support as a new immigrant family to Canada. And so I actually took on a lot of the caretaking at home looking after my grandma. And it was really eye-opening, even at that young age, to recognize that this person that I knew and loved, who was so patient and quiet and calm pre-stroke, following the stroke, had such huge shifts in terms of not only her physical capability, but also her cognitive capacity. I remember it was almost like dealing with a toddler at the time, but with my grandma. And so it got me really interested in neurosciences and neurology and neurophysiology, how something so tiny as a two-millimeter clot in the brain could fundamentally change the course of someone's life. And so when I went into undergraduate studies at Queen's University, I picked neurosciences, life sciences, mostly being led by that interest in neurology. When I got into medical school, I initially thought I wanted to do neurology and then ultimately ended up doing a number of electives in emergency medicine. I had the great fortune of working with a couple of fantastic mentors, many of whom were with Starz Air Ambulance at the time as transport physicians. And I remember looking at all of these incredible physicians and thinking, this is what I want to do when I grow up. And that's really what set me on the trajectory of where I am today with my clinical practice.

SPEAKER_02 3:37

Wow, I have to say I did not expect that. That's quite the story. Can I ask a couple of follow-up questions? How old were you? Did you say when your grandmother had a stroke?

SPEAKER_00 3:44

I was 13 when she had her stroke.

SPEAKER_02 3:46

Wow. Wow. And now you're a stroke attending with the Calgary Stroke Program. That's quite something.

Crisis Resource Management (CRM)

SPEAKER_02 3:52

And before we get into the specifics of CRM, can you give us an overview of what we mean, particularly in medicine, when we talk about CRM?

SPEAKER_00 4:02

The core crisis resource management is really a framework for how we can improve human and team performance in crisis situations when there's time pressure, personnel pressure, you don't have a lot of hands on deck. And that is particularly true, I think, in the resuscitation environment that I'm part of in emergency medicine and stroke, in the pre-hospital world, in so many fields, including anesthesia, as you know, Adam and Amir. And really, I think that dedicated CRM training provides your team and your personnel with the skills and techniques that help you manage everyone in terms of a communication perspective and allows everyone to perform at a high level with great efficiency. Because I think at the end of the day, the actual medicine is really only one part of the equation. It's how we actually carry out those assessments, how we synthesize information, how we prioritize and triage any key interventions that we need to deliver to the patient, that determines how effective we can be as clinicians. And that's really amplified when we work as part of a team. There are lots of moving parts. There are lots of different personalities in the room. How we coordinate our efforts with the other members of our team, such as our nurses, our respiratory therapists, our consultants, that's going to dictate success.

SPEAKER_02 5:22

I really liked how you wrapped that all together. And for listeners of the podcast, in the first few episodes, we talked about, for instance, the Elaine Bromley case of a can't intubate, can't oxygenate scenario, and how, as her husband Martin Bromley put it, that that was a failure of human performance. And CRM is one of the tools that we have in order to try to address human and team performance, really. And as you say, it's not about the individual skills. And so things that we're not talking about, for example, we're not talking about specific skill sets like how to perform an intubation, how to insert a chest tube or a central line. Those are specific skill sets that we assume that high-performing teams already know how to do. And for example, the team in Elaine Bromley's case knew how to perform a cricothyrotomy or front-of-the-neck access to obtain a surgical access to the airway. But the question is why didn't they perform that? And so is it fair to say, Katie, that when we're talking about crisis resource management, that it's a bit of a shorthand for how people are interacting with each other, that they're subject to human factors such as rushing and fatigue and emotion and forgetting and fixation and things like that. We talked a little bit about communication, or at least you mentioned communication a little bit and how there are some strategies that we're going to talk about throughout this episode of how to mitigate the risk of miscommunication and the fact that each clinical case has unique features. And we'll talk about things like problem solving and conflict resolution and workload management and so on. Is it fair to say those things?

SPEAKER_00 6:44

Well, all of those I think are true, right? We're all human. We're working in imperfect and really complicated systems. And so taking that into account, thinking intentionally about how we communicate with one another effectively, and then allowing ourselves to maintain situational awareness and stay dynamic in our approach, I think is really the key for being effective in the clinical realm.

SPEAKER_01 7:08

I like the terminology that you said stay dynamic in our clinical approach. Can you elaborate on what you mean by that?

SPEAKER_00 7:15

Yeah, every situation you walk into is slightly different. Even if you're dealing with the exact same type of resuscitation. So, for example, if I'm running a cardiac arrest code, that same code, if I run it at a big tertiary care trauma center like the Foothills Hospital, is a very different environment in terms of my communication style with a team that is used to working together, has run these codes day in, day out. It's kind of automated. Versus if I'm running that same code when I'm going out on a STARS flight and I'm in a rural center with way fewer people, and maybe that team doesn't necessarily work together very frequently, or maybe there's new members to that team, or maybe this is the first time there's a new staff who's been running a resuscitation, how I communicate, how I run that resuscitation, how I prioritize my CRM goals is going to be different. And so I think that as team leads and as team members, when we walk into these scenarios, we just have to recognize that we're constantly adapting to the patient, to the environment, and to the other members of the team. That context, you have to be very dynamic in navigating.

Katie's background in CRM

SPEAKER_02 8:24

So, Katie, I'm gonna ask you a little bit more about specifics about CRM in a minute, but can I just get a little bit of your background in terms of CRM? I understand you have a master's of public health from Harvard on focused on clinical effectiveness. Can you tell us a little bit about that and how you got became interested in crisis resource management?

SPEAKER_00 8:40

Certainly. To be honest, the practice I've had in CRM has largely been informal. And it's mostly through the work that I do. So through all of my clinical roles as an emergency physician at a large trauma center, as a stroke physician at a comprehensive stroke center, and then in my critical care transport role with SARS Air Ambulance, CRM really is foundational for the work that I do. When I first started in emergency medicine, CRM was a specific topic that's baked into our residency training program in Calgary, primarily through simulation practice. So in Calgary, we run multidisciplinary SIMs at the resident and the staff levels. And we do these in really realistic spaces with hyper-realistic patient models. And we invite our nurses, our respiratory therapists, our healthcare aides all to come join us for these multidisciplinary SIMs as well to make it more realistic so that we're actually doing the roles that we would actually be doing. And we're practicing that communication piece. And typically, our SIM scenarios are actually more focused on how we effectively lead the team and communicate as a group together. It's about resolving conflict in real time. So some of our scenarios specifically throw in wrenches related to conflict with consultants, for example, or how do you resolve a safety issue that maybe one member of the team is given that information and they have to communicate that effectively to other members of the team. And I think it really also allows you to develop appreciation for the expertise that other members of your team bring to the table and how to leverage that most effectively when you're doing a team-based resuscitation. I think simulation is a fantastic way to practice those skills and then also to receive feedback on your own skill set and your own practice from other members of the team. What did I do well? What could we do better together? And how can I identify and lean on my individual leadership styles and strengths? Because there are many different ways to lead a team effectively, many different leadership styles. So that's from the training perspective. When I started in residency, it was largely simulation-based. But then when I transitioned to staff, my daily work became a part of that practice. Every time you step into the trauma bay, every time you're at the bedside for a really sick patient, you're practicing these skills. And, you know, when you have a level one trauma with 20 or 30 people in the room, on top of the medicine that you have to contend with, CRM becomes really important for how you can coordinate all those 20 or 30 hands to do what needs to be done in synchrony for that complex resuscitation.

Different types of resuscitation requiring different CRM skills

SPEAKER_00 11:27

When I stepped into my STARS Air Ambulance Transport Physician role, things shifted again a little bit because I was so used to leading resuscitations in person. But then when you start to do pre-hospital transport medicine, a lot of that is done virtually, right? So I'm providing support for colleagues who are out in the periphery in rural or remote sites calling in for help. And I'm trying to provide resuscitation advice and gather information and coordinate care through a phone line. Or more recently, we've started doing virtual care with a video feed as well. So I can actually see what the patient looks like. I've actually run resuscitations and I've coached colleagues through intubations through a video feed where I just have them pass the phone to a paramedic or an extra set of hands that's just available, bystanders even, and just ask them to direct me where we need to go, put me on speakerphone, and I will run the code while you are task focused on some specific but critical intervention or procedure. And so that skill set is also completely different, including if I'm on the phone and I've got 10 other consultant voices on the line, but I don't have the body language, the tone, the connection, the relationships that I am used to having with in-person CRM leadership. That was another transitional stage and another type of skill set that I then had to develop over the course of the last couple of years as I've worked with stars.

SPEAKER_02 12:52

I have to say, I'm just I'm so impressed that the number of different modalities of resuscitation that you have to go through and each with their own different fidelity of communication and different set of staff and different set of circumstances. We'll definitely have to have you on to talk about some of those more unique aspects there. That was quite something. I just wanted to hit upon a few things that you had mentioned there. You mentioned training in residency, you mentioned specifically simulator training as a way to practice very specific skill sets. And I think that'll become really important because people might be listening to this podcast and say, okay, great, we're going to talk about things like how to escalate the language of concern, which is the title of this episode. But the reality is that like any skill, it has to be something that comes naturally and it only really comes naturally after you've practiced it a number of times. So thank you very much for that. Um,

CRM as a formal concept in other industries

SPEAKER_02 13:40

can you just briefly tell us how you think CRM looks in medicine as compared to perhaps aviation or other industries as to where it came from?

SPEAKER_00 13:50

I think that CRM as a formal concept, a formal approach is a lot more established in many other industries. It's relatively new that we're transitioning it into medicine on the grand scheme of things. But lots of those same principles when it comes to CRM from other industries, like aviation, military practice, even professional sports, for example, I think they can be applied very effectively in the medical context as well. Some examples of that might be the use of checklists, closed loop communication that we're now stressing so much with our teams, and the use of formal safety escalation language, which I know we're going to get to a little bit later in this segment. But I think that the challenge when it comes to CRM in medicine is that in many other fields, CRM is baked into the practice of those professions. It's baked into the training, the onboarding at all stages. And so people have a certain set standard of language, of operational interactions, of how things are done and protocols that are based on CRM principles in those other fields, like aviation, especially. But we don't have those same standards in medicine. We're kind of just thrown into it and you figure it out and you sink or swim to a large extent, but obviously with graded responsibility. But it's not necessarily a formalized curriculum that we go through when we're training. And so we kind of pick it up as we go.

SPEAKER_02 15:16

I think that last point was really what struck home for me, which was this idea that CRM is definitely something that it has been around in medicine for a little bit, and it's certainly there and available to people that are interested in seeking it out. But as you say, it's there in almost its nascency when it comes to medicine, as opposed to we talked in other episodes in this podcast about how in aviation we're into the sixth generation of it and how it started as modules that we would say, okay, we're gonna have a PowerPoint presentation on attitudes and behaviors, and a separate PowerPoint module on problem solving and a separate one on leadership, for example, and then how it came into the actual practice of things, and then how it was not just the big emergencies, but now it was these smaller emergencies that snowballed and took down aircraft in real life and how we can prevent those. And then it even went further, and now we see what's called threatener management, which is where you basically have integrated into the airline's operations how this actually plays out in real time. And so that's really what we're looking at now. We're not necessarily there in terms of medicine, and that's in large part because, as you say, there isn't necessarily the same formalized curriculum. It doesn't exist in the same manner across all residency programs. You really do have to seek out a lot of this and be a sort of believer in CRM, if I can use that word, in order to then go forward and say, okay, well, I'm going to integrate this because I believe that it's important for my practice and then go forward. It's always difficult to discuss specific examples of patient safety, but if you're able to, can you give us examples of some of the situations you were talking about where you that might highlight the importance of CRM?

SPEAKER_00 16:52

Probably a good example to bring up. I just finished 36 hours of call with SARS over this past weekend, but we can do some de-identified old SARS cases really where I think CRM shines.

CRM as conflict resolution and improving efficiency

SPEAKER_00 17:06

So, just as an example, recently I had a very busy STARS call shift where I was brought onto a phone consult that involved a patient who was currently in another province. And I was asked to help resolve some transport logistics, but also mediate a little bit of the conflict that had arisen on this phone call that involved a pediatric trauma case in another province. And so these are always complex for multiple reasons. There are so many voices on the line. I think in this case we had eight different consultants, both adult and pediatric, because this was a teenage patient, and they often fall between the two services to determine where they go. Do they go to an adult trauma center? Do they go to a pediatric trauma center, depending on the specific type of trauma and the subspecialists involved? So we end up having to bring a lot of different people to the line. And I think what made this call particularly challenging is being dropped into the middle of this, where there had already been a little bit of back and forth friction and conflict and disagreement and just lots of voices on the line, which always makes it quite difficult. And so my strategy for calls like this is always to start by introducing myself and specifically my role to clarify what I'm there to help everybody with. And I immediately can hopefully with that establish some common ground so that people are willing to talk to me and explain what's going on. And then I really try and clarify quite quickly who on the call is the one who's best positioned to give me just a brief and concise handover on what's happened so far. And then I can take on a bit more of a director role for the actual flow of the discussion moving forward. Because like an air traffic controller for an airport, you really need somebody who is centrally making that decision when there are that many people involved. And for me, the priority whenever I start with these calls is always first to understand if there are any time critical patient management priorities that we need to address. Is the patient stable or unstable? Are there any fires that we actually need to put out first before we can address the other bits? This is that kind of prioritization piece. And if that patient does need to be stabilized, then we don't really have time to chit-chat. And I become a little bit more authoritative and concise in my instructions on the line because my decision making has to be much more quick and rapid when it comes to resource mobilization. If the patient is stable on the other hand, as was this case, then we have more time to sort out the details, to invite more open discussion, to take on more of that collaborative, collegial type of tone on the call. And in this case, we were able to discuss the case at hand. The patient was in stable condition. And so we were able to come to an agreement between the various surgeons on the line on which hospital this patient would be best served at, based on the availability of subspecialty trauma and orthopedic surgery capability. But the other piece that I think CRM really helped us with is that this case came in the middle of the night and it was winter time, the roads were icy and very, very slick. We had already fielded multiple car crash calls with stars as well with the stormy conditions. And so while we could send our crews out into this, we could coordinate the transport overnight. I also really took a moment to pause the team and say, you know, what's the urgency here? I need to hear from our surgeons to let us know how quickly you are going to mobilize this operating room for this patient. Because if you're going to do it overnight, if there's any neurovascular compromise or the patient's unstable, then absolutely we are going to do what needs to be done. But if the patient is in stable condition and you wouldn't be planning for an OR until the morning anyway, then I truly think it's safer for our transport teams and for the patient and their family members themselves, if we are actually able to hold them in the sending facility until daytime hours, until the transport conditions are actually safer. And so that's what we actually ended up doing for this case. And I'm just particularly cognizant of that part of the CRM too, which is keeping your team members safe because medical transport is incredibly safe, particularly in Canada, because we have so many rules and regulations, but we have absolutely lost team members in transport accidents. And I'm always cognizant of that. Whenever I send my crew out to pick someone up, I want to make sure that I can bring them home safely. So those are just some of the considerations when dropping into these calls.

SPEAKER_02 21:33

Absolutely. And I really appreciate your thinking of the safety of the transportation team on the air side of things. I've lost some friends and colleagues to exactly that sort of thing. So I really appreciate that. I'm just gonna feed back to you some of the things that I heard you say that I thought was really fantastic. It sounds to me like you had said that one of the first things you do is establish communications and your role that you try and build at least a little bit of rapport and some buy in from the team members, that you then gather information properly. Prioritize threats to life and then prioritize treatment and transportation. And then on an ongoing basis, that you again continuously gather more information and reevaluate those decisions with a view to not only the patients' safety, but also the transportation teams. Anything I missed out there?

SPEAKER_00 22:18

I think you've summarized it well.

SPEAKER_01 22:20

Yeah, I just wanted to say I think it's a really good example, a really pertinent example to really solidify the conspiracy or like I remember as a medical learner, and still to this day, when I see some of my more experienced and adept colleagues manage crises, whether they be codes, trums, even difficult patient encounters, we all walk away from those situations. Like, that person did that really well. And I think sometimes we sit back and we're like, why did they do it so well? Like it just seemed like that was common sense and like straightforward. But I really like your linking back to principles of CRM and your summary of that, Adam, because what we're trying to do here is demonstrate that it isn't just something that happens de novo. Some people are actually naturally gifted and skilled and able to do this, but there is not necessarily a formula per se, but perhaps a structure or some frameworks we can all use to adapt to some of those

CRM as a skill that can be learned and and the need to maintain proficiency

SPEAKER_01 23:00

skills. Can you give us some concrete definitions of CRM, some good examples of CRM?

SPEAKER_00 23:05

When it comes down to CRM, it's really doing the right thing at the right time with the right resources for the right patient or for the case that's in front of you or the situation that's in front of you. And while there are foundational principles of CRM that help to provide guidance for us, actual effective implementation of CRM in real world scenarios does require a set of skills that all take practice, as you mentioned before. And our tools and our frameworks are only as good as our practice of them. I'm not going to be great at doing an emergency crike or a chest tube if I have never practiced or thought about it before. And so that's the same, I think, when it comes to communication skills and CRM in times of crisis. So that involves situational awareness, dynamic decision making, strong communication skills with the other members of your team and strategies that help us to coordinate those team dynamics. I'm really a firm believer that all of that begins with a foundation of trust and mutual respect with other people who are involved in the team in order for everybody to operate well under pressure. And I think that the calmer we are, the more organized we are, and the better we are able to resist that temptation of tunnel visioning and missing the important pieces of the puzzle that we need to be paying attention

How managing your stress response, (being calm) which allows you to maintain situational awareness (“slow is smooth, smooth is fast”)

SPEAKER_00 24:30

to.

SPEAKER_01 24:30

You mentioned the term situational awareness and you mentioned being calm. Are those the same thing?

SPEAKER_00 24:35

I don't know that they're necessarily the same thing, but they are intimately linked with one another. When I'm feeling panicked, stressed, I'm really adrenergically driven or sympathetically driven, I tend to tunnel vision just like everybody else. We're human, and that's kind of adaptively what we've been designed to do or what we've evolved to do. And so the calmer I can keep myself, the better I'm able to scan the rest of my environment, not get tunnel visioned into one particular thing and miss important cues in other parts of my environment that are super important. And so, really, when it comes to situational awareness, if you aren't aware of what's going on, the inputs aren't coming in, you cannot effectively adapt your communication strategies. You can't notice when other members of your team are hesitant or struggling or they haven't actually closed the loop with you on something that was super important. You also can't necessarily prioritize your management goals because you're not able to identify all of the important goals that need to be dealt with either. And so for me, it always starts with grounding myself because the more cognitive overload is present, the more tunnel-visioned we become, like we talked about earlier. So for me, I take a breath and I really like the mantra of slow is smooth and smooth is fast. And that reminds me that before I jump into any busy or chaotic scenario, that if I take a systematic approach and I use my frameworks, I will be able to be effective here. That helps me to avoid that fixation error that can so easily come into play when things get really, really complicated or chaotic. And it lets me stay connected with the rest of my team and with what's going on in the environment around

How Katie practices CRM during a resuscitation

SPEAKER_00 26:17

me. And then I've practiced and specifically thought about strategies for scanning the environment effectively, systematically for clues that are most important. I usually position myself very intentionally at the foot of the bed because then I can have an overview of the situation, but the overview of the other team members as well. I can see all of the monitors, I can tell pretty quickly if this patient looks critically sick or not sick, and that determines the time frame that I have to make some of those initial decisions and my first couple of moves and priorities. I can identify if there's anything I need to quickly intervene on. And then it also I think forces me to be a little bit more hands-off so that I don't get task-focused by getting engaged in a particular procedure or particular task, but it allows me to keep an eye on the overall situation and the team around me. And again, all of that takes intentional practice. Some of that practice can be through sim, like we talked about before, but I also think that you can effectively do visualization sim in your own head. We've got quite a lot of evidence from the world of professional sports, for example, that visualization practice can also lead to pretty impressive results over time. But ultimately, like any other skill, it can feel a little bit clunky at first. It's not going to be perfect. And often it can be really cognitively heavy until you've automated parts of it, like the scanning for clues or the decision making, because you now have these heuristics that you can fall back on. So at first it feels really clunky, but if you keep practicing systematically over and over until those parts become automated, it becomes more and more efficient and you're able to tackle it a lot more effectively.

SPEAKER_02 28:03

I'm just going to jump in here and highlight a couple of things, just

Defining situational awareness

SPEAKER_02 28:06

because medicine doesn't necessarily have the same familiarity with CRM and the definitions and things like that. And so in the previous episode when we talked to Captain Mike Schuster, they have definitions there and so on. And so from aviation, if I just give the definition for situational awareness, they would define it as 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. That's a lot of very highfalutin language there, basically, to essentially say to notice and integrate what is going on around you. And so in the previous episodes, we talked about fixation-induced loss of situational awareness. And it's exactly what it sounds like. You are so fixated in the case of Elaine Bromley on intubating a patient that you've lost the idea that's we need to abandon that approach because it's been such a long time that this patient has been without oxygen, for example, and they need to go for front of neck access. Whereas the nurses didn't necessarily lose their situational awareness because they weren't so fixated on the task, and that's why they brought in the cricket kit, for example, and things like that. So I think that's one thing. We also talked about, in terms of the discussion that just happened between Amir and Katie, about things like how to manage your own cognitive load, how to manage your own emotions, how to manage your own physiology so that you can then extract those that information and perform at your best and so on. And that is its own separate piece. And then the third thing that I wanted to mention was we talk about shared situational awareness with others and mental models. So as we become experts in various domains of medicine, Katie was talking about the fact that we have what I would call schemas essentially, where we would say, okay, perhaps I can task this person to do a chest tube, for example, and that person has a schema, or they have, for instance, this is a tension pneumothorax, and that's my schema. One of those actions that might need to happen is to decompress the chest, for example, and that can be done in the following way. And so we have these broad schemas that we can rely on. And as long as the room then knows that this is what's going on, then they can also help keep all of the rest of us inform our situational awareness because I might be so focused on the tension pneumothorax that I don't realize that there's actually a bigger problem of exanguination or what have you, and so on. And so there, this is these are sorts of the things that we're going to be getting into in here.

unknown 30:28

Yeah.

SPEAKER_00 30:28

And Adam, just to double-click on what you just said, when it comes to situational awareness, I think about it in three parts. Part one is the noticing. So I have to be able to notice or I can't process. Part two is the processing. So once I've noticed it, am I actually paying attention to it and recognizing its significance? And then that third part is predicting and preparing. So once I have that information, I've processed that information, what am I going to do with it? Can I predict what's going to happen next because of what I've just noticed? And can I start to prepare for it and take action?

SPEAKER_01 31:01

Can you give advice on how we actually practice this? Is there something we can do day to day or small cases to actually integrate this in?

SPEAKER_00 31:07

I would say a couple of suggestions that I think are really great to get someone started if this isn't something that they've had a chance to practice before. The first is to think about a couple of key phrases that you can practice on your own in those critical moments. For example, for me, when I notice something in the room, like SATS dropping, for example, or a change on the rhythm monitor, what phrase can you use with your team that feels natural but is going to draw people's attention? So for me, I often will say critical finding, or I have a critical finding. And that allows me to feel comfortable then speaking up about it. But if I haven't practiced that phrase before, you don't want to be trying to think of something in the moment that's going to allow you to get the attention of your team, start directing things. So that's one of the things that I do. I also have other phrases for when I am establishing my role as a team leader. So when a patient first comes into our department and EMS is bringing them in on their stretcher, I establish my role as the team leader right away so that there is no ambiguity. And I think that helps to set the tone for a more controlled resuscitation. So often I will say something along the lines of, hey, I'm Dr. Lin, we're going to trauma bay one. Let's get the patient transferred over and then we'll get the story all together. I want the volume in the room low. And it just establishes those expectations very calmly, but very quickly. So those are some of the frameworks that I like to use. Another language piece that I really like is when I'm I've received that handover from my paramedic team, I'm just going to recap my mental model and share that with the team and say, hey, we've got a patient here in respiratory failure. My top three priorities are this. And then I'll delegate that. And that I think also is an intentional practice of certain language that you might want to use. So just think about what phrases might work for you in your clinical practice environment. Practice them at home on yourself with your family members or with your friends and feel how that feels when you say those words. Because I think the more we do that, the more comfortable we can bring that into our clinical spaces. The second thing that I think is fairly easy to do, especially if you don't have somewhere where you have an established simulation program, is visualization training. When I was a resident, particularly preparing for my royal college exams for emergency medicine, we have an oral exam component to things where we're asked to walk through resuscitation, usually of a complicated case. And I set up these frameworks for myself for the first five minutes or the first 10 minutes. What do the first 10 minutes look like for big broad strokes presentations to the emergency department? Respiratory failure. What do my first 10 minutes look like? If the patient rolls through the door, I'm literally envisioning myself standing at the foot of the bed with my team around me. What am I going to say? How am I going to move? What am I paying attention to in the room at any given moment? In what order? And I'm just rerunning those visualization sims over and over in my own head until I feel like I've tweaked it to be as efficient as possible or as effective as possible. And then I can go into the real world and start actually practicing that. How does that feel? Well, maybe my visualization was a little bit off. I can then tweak it the next time when I go through my mental model practice. But I did this for all sorts of major, major level one trauma. I did it for pregnant patient unwell. I did it for the crashing neonate. And just what do those first 10 minutes actually look like? And that made me way more comfortable both going into my oral exams, but actually more importantly, using that same framework and approach in actual clinical practice when I saw those cases.

Leading a resuscitation in less resource rich areas

SPEAKER_02 34:55

Katie, can I jump in there for just a second? You mentioned leading very large teams. Can you talk a little bit about what it's like when you are in a less resource-rich scenario where you might be one of the only physicians in the room and only have a few nurses?

SPEAKER_00 35:16

Especially if you have one or two really sick patients in your department, it is so cognitively overloading and it absorbs your resources instantly. In these moments, in addition to I think setting that tone for calm and systematic resuscitation, for me, I think the most important thing is I am the holder of the big picture. As the holder of the big picture and the team leader, I have to be very aware of the number of people I have to task to various things. And I have to be incredibly intentional about how I choose the priority of those tasks because I can't just spew out the 20 different medications and orders and procedures that I want to have ideally done simultaneously. I just can't do that. We can't physically carry that out. So I have to be much more intentional about chunking it and truly parsing it down to these are the top one or two things that I need my team to do right now. So this med is the most important med in this second or this minute. Until this medication is given, I cannot move on to the next one. Or until I've established IV access on this patient, I can't move on to the rest of my resuscitation at all. So that needs to become the number one priority. And I need all hands on deck with that priority. But in my head, I have a ranked list of the priorities that go down for the entire resuscitation. I have to be very intentional about when I release those orders to the rest of my team. So I'm not overloading them and I can ask them to carry out this particular order and then come back because that's priority. Let me know when you're ready for the next one and I will give you that next one. And there might be certain things that I have to let go of, but I have to intentionally decide on what can be, what can be deprioritized because I have fewer people. I think the other part of it as well is using other strategies to cognitively offload yourself whenever possible. So I'm a huge fan of whether you use a computer on shift or if you just have an old pen and paper notebook strategy in a really busy resuscitation or a complicated case. If I'm doing, let's say, a toxic logic arrest and there's just a lot of stuff that needs to be given. I will actually write down a list of the medications that I will need from my nursing team and I chunk it into the top three, the next three, three after that. And I will write them all down into a wish list and I will hand it to my charge nurse or my med nurse and say, I want these three meds first, these three meds next, and these ones after that. Can you please let me know when each of those is given? And then I've now tasked them for the next 10, 15 minutes and I can focus my attention elsewhere, but I haven't forgotten any of those elements and it's allowed me to cognitively offload some of those really important things onto another member of my team who now has direction for where to go.

SPEAKER_02 38:11

That's really helpful. Thank you so much. I was just gonna say that I asked the question because some people might be thinking, oh, I don't work in a big academic center, and maybe CRM isn't as important because I don't have 20 people. But it sounds like what you're saying is that it becomes almost at least as important, if not more important, because as you said, you just have fewer resources to work with and you have to be the holder of the big picture and you have to judiciously use those resources in an appropriate manner and really prioritize to an even better degree.

SPEAKER_00 38:39

Absolutely. I think sometimes in those settings when I've, you know, walked into a rural resuscitation and you don't really have a lot of people available to help. That's the moment where I gather my information up front and I take those 10, 20 seconds to really pause and reflect on my next top priorities and create that list, right? So take that moment to pause and then you can go ahead with an organized strategy, especially when you are resource limited.

How Katie’s CRM skills have evolved

SPEAKER_01 39:07

It seems like there's some concrete things that have really come out of your CRM knowledge and skills. Number one is the idea of prioritization. It's very clear that the concept of prioritization is key from crisis resource management because it allows you to not be overwhelmed by all the things and you are forced yourself to look at it that way. The second thing I want to point out is some degree of delegation, but actually able to offload some of the tasks. So you're not necessarily worried about all the meds being given, but furthermore, the priority of the meds being given allows you to say, hey, that's being done over there. And I think all of the understanding or the undertone is that there's clear communication, not necessarily saying more authoritative, unless you said like at the beginning you have to be, but just more direct. You're not speaking into a void, you're not giving vague tasks, you're actually appointing them to very specific people and allowing them to follow up with you as being completed. Is that fair to say?

SPEAKER_00 39:54

Yeah, I would say that one of the biggest skills within CRM that that I've had to train myself on is to be clear, to be concise, and to be very specific in what I'm asking for. Because in the heat of the moment, it's very easy for things to get misunderstood or misconstrued or misheard. And so I just want to be very clear, very concise. I'm cutting down on unnecessary words or unnecessary orders and really drilling down on what I need right now. But I'm also establishing expectations for closing that loop of communication. Because again, I don't necessarily assume that other members of the team have had dedicated CRM training. So I can just establish what we're gonna have the standards be for this particular resuscitation, right? So please close a loop with me when you have given that medication so that you know what my expectations are and you don't have to guess what I'm thinking or read my mind. And I think that's a really important part of it as well.

FRCP CRM Handbook

SPEAKER_02 40:57

And we're back. Okay, so we're talking to Dr. Katie Lynn, and now we're gonna segue into specific interventions with regards to crisis resource management. And we're always looking for good resources. So, Katie, can you talk to us a little bit about this CRM handbook?

SPEAKER_00 41:13

Yeah, I came across this a couple of years ago, but I think you're referring to Adam, the Royal College of Physicians and Surgeons of Canada handbook on optimizing CRM to improve patient safety and team performance. So this was put together and published in 2017 by an Edmonton ICU colleague of mine, Dr. Peter Brindley, who is an exceptional CRMist and educator and critical care intensivist, and his co-editor, Dr. Pierre Cardinal. It's a great resource, truly, for practicing physicians to just familiarize themselves with CRM principles and specifically how they can be applied to medical practice. It is free, it's online, it's a PDF through the Royal College website, and it's a great starting point. You can probably Google it for anyone who really wants to just look at a well-laid out, basic resource on the topic of CRM.

SPEAKER_02 42:05

Fantastic. And I will put a link in the show notes and highly suggest people checking this out. And we're going to look at a few different things. We've talked a little bit about individual factors and ways that we can learn to practice CRM a little bit better as practitioners, as well as leaders of teams, whether that's a small team of a few nurses or whether that's a much larger team as the kinds of ones that you're used to, Dr. Lynn.

Cultivating Situational Awareness

SPEAKER_02 42:26

When we look at this, can we talk about more specific nuts and bolts? So, what do we mean when we talk about cultivating situational awareness? We talked about the definition before and really how it is, in fact, noticing the information, accurately identifying what is going on, accurately prioritizing and then predicting what needs to happen in the future. But what do we mean when we say cultivating situational awareness?

SPEAKER_00 42:49

So if we break it down into the micro skills that contribute towards situational awareness, I would say part of it is scanning your environment for clues or cues. So where do you stand in the room? And what are you paying attention to? What are you specifically looking at? So for me, I'm standing at the foot of the bed. I'm looking at the monitors and I'm looking at the patient in front of me. And through my peripheral vision, I'm also paying attention to the movement and positioning of the rest of my team. Are there too many people in the room in a really big level one resuscitation? Maybe I need to ask people to actually step out if they're not actively being involved. If there's not enough people in the room, then I know I'm gonna have to proceed very conscientiously with my priorities, like we talked about before, when you've got a small team and you're resource limited. So scanning that environment for cues and then creating habits for myself. So periodically, I just have trained myself. I'm looking back at the monitors again. What's the rhythm showing? What are the vital signs every couple of minutes or so? Right. It just automatically that's where my eyes now start to land and rest. And I have scanning protocols of where visually I'm paying attention. Certain strategies that we talked about for avoiding fixation error. So for me, that's hands off patient. Initially, if I have that luxury, if I'm in the periphery or I'm responding to the side of a highway with a STARS call, I may not have that luxury and I have to be part of that initial assessment. But trying to avoid the fixation error that comes with stopping my assessment of a patient once I've identified the first thing, I really need to be systematic about how I'm choosing to do that assessment and what I'm paying attention to in what specific order, what's going to kill the patient the fastest, right? And try not to get myself stuck in a complicated procedure where I'm going to lose all situational awareness and start to tunnel vision down. Those strategies we talked about for keeping yourself calm when you've got a really high stakes, high stress situation. Often, for example, if I've got a pediatric resuscitation coming in or a pregnant patient resuscitation, these are often very emotional and stressful in a different way for our teams, partly because they don't come very often, and partly I think there's that extra emotionality of that particular patient population. And so I often will take the time to pre-brief my team. What do we know so far? And really just acknowledge the elephant in the room and say, hey, this is potentially going to be an emotional case, but we are equipped to deal with this. Here's what we're going to do. And I think just taking that moment to help everybody emotionally regulate and ground ourselves in the work that we are about to jump into. And then other things that are so important are part of that predicting and preparing piece and utilizing my team with the situation that I've become aware of would be sharing my mental model. So here's the overall presentation, what we know so far. Here are my priorities. And taking that moment to invite the rest of your team to have some input if you have the time to do. So here's my mental model, here's what I think the diagnosis is, or here's my top three priorities. Does anyone else have any other thoughts? And I think that opens the door for the rest of your team to let you know if maybe they've noticed something that you yourself have not noticed. Maybe they got some collateral history from the family members who have just arrived, or they were able to find ID on the patient so they can look them up now. That piece is so important to make sure that you've actually gathered all the information that you can to make a better informed decision. And maybe they've thought of something that you haven't thought of, or maybe they have seen something that you haven't seen with the situation itself. So that is part of the situational awareness because if I'm using my team as part of my situational awareness, it just expands my ability to track more things than I could ever do alone.

SPEAKER_02 46:40

I'm just going to summarize a little bit there. And you mentioned four big buckets in terms of cultivating situational awareness. You mentioned scanning the environment for cues and how you do that. You mentioned strategies for avoiding fixation error. And then you talked about how to keep yourself calm, how to avoid those stimulus overload. And then the fourth thing was sharing that mental model and inviting input from the team. And I'm just gonna put a bit of a distinguishing feature on there, which is that the situational awareness is really the actual situation that is going on and how we are aware and how accurate that is for us. Whereas the mental model might be your schema and what you're thinking. And so you said specifically, Katie, that you will share your mental model. This is a X kind of situation, and you are thinking about the following priorities, and then invite the team to provide input or even correct you because they may see something different, and you may have just a slightly incorrect mental model, and your situation awareness might need to be improved a little bit by that input from the team.

Interpersonal skills in CRM, including useful phrases

SPEAKER_02 47:38

And so uh as we've seen in aviation, there's a lot of actual implementation of team dynamics comes down to those interpersonal skills, particularly in crisis management. Do you have any specific strategies that practitioners can use here?

SPEAKER_00 47:52

I have a couple of principles that I've found to be particularly important in these interactions. The first is role clarity. So it's really important that people know what roles they are playing within this team. And I also think it's really important to establish myself as team lead fairly quickly. So that role clarity piece, specifically coming out and saying, I am Dr. Lin, I will be running this resuscitation. Who else do I have in the room with me? And particularly when I'm with stars, for example, and I'm being dropped into a team I have not worked with before, I need to know who else is in the room with me, what their skill set is, what their roles are, so that I can more accurately task them to the things that need to be done. The second big principle for me is that it has to begin with mutual respect and professionalism, because I think that's the foundation that allows us to find that common ground to work together as a team and to avoid the conflict that can distract us from being able to do our work effectively. Even when there's a disagreement, I think there are ways to have that disagreement in a mutually respectful and professional manner. And if that's not necessarily happening in the interaction, I have certain phrases that I like to use to de-escalate or to set some gentle boundaries to help get us back on track. But ultimately, I think if you find yourself in a situation where that conflict has arisen or when you're feeling just particularly chaotic, not grounded, that pause becomes so important. So take that internal pause, take that breath, and then really try and intentionally focus on depersonalizing things and focusing on that common ground, shared space. So some of the phrases that I've that I use fairly frequently in my work, the first is if I'm on a recorded call for a consult, for example, and things are going off the rails, I just take a moment to essentially say on the line, I'm just reminding everyone that this is a recorded call. And I think sometimes that is enough of a nudge to get people back into that professional zone because they can forget in the heat of the moment when emotions are running high. And I think that's just a gentle reminder without necessarily putting anyone into the defensive that this is a professional space and there are certain expectations with that interaction. The other phrases that I like to use, I often really think it's important to validate and acknowledge what's going on, or acknowledge that the interaction has gone off sideways. So I will specifically say this is a challenging situation, and I really think we've gotten off to the wrong start. Can we just pause and reset? Can we start again? And sometimes that can help to just wipe the slate clean, allow us to both take a bit of a breath, regulate ourselves, and then jump back into the situation, really specifically focusing on a productive direction. And the final strategy that I often use is something along the lines of 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. And I think we can agree on X, Y, Z. What is our common ground? I'm reorienting ourselves back to that alignment on common ground, but I think it also injects that undercurrent of respect, the acknowledgement of the other person's expertise and the role that I'm asking them to play in this interaction. And I think it also helps to tap into that helping mindset that so many of us found that brought us to medicine in the first place. And so those are some of the practical strategies and phrases that I like to use to help with some of those challenging interpersonal dynamics.

SPEAKER_02 51:42

That's really fantastic. Thank you so much for sharing all of that. Can you give us some strategies for de-escalating the room in order to really bring out that team performance in resuscitation?

SPEAKER_00 51:53

I think a calm room is an effective room. Everyone can be way more situationally aware and less tunnel-visioned when there's less unnecessary noise or stress or chaos or distraction getting in the way of that situational awareness. And so that means not only do I have a big picture sense of what's going on in the room as the team lead, but I want to create an environment where the other members of my team can also serve as extra eyes and extra ears to expand that sphere of situational awareness. I think it also creates less risk for orders to be forgotten or to get missed in the shuffle. And I think it also reduces any delays to recognizing when there's patient deterioration or a change in status, because we're not distracted by these other extraneous things. There are a couple of things that can be really helpful. So we talked before about that shared mental model. If I share with my team what I think is going on, how I've integrated that information and what my priorities are, it allows my team to then watch for my blind spots to anticipate and prepare for the things that I likely will need down the road, especially if you have a fairly experienced team. So a lot of our nurses, for example, at our major trauma center, if I tell them, I think this is a status epilepticus patient, they've already drawn up the next three rounds of medications without me even having to ask. So by the time I do ask for it, it's already there. That's just a quick example of things, but everyone is dialed in, I think. Or if I announce to the team, I've got a difficult airway, this is going to be a difficult airway, that allows everyone to dial it back in as well. No side conversations. The RTs or the nurses have brought over the difficult airway cart. Everyone is paying attention very closely to how that intubation proceeds because they know that they might need to call for help very quickly or things could go south very quickly. And so I think it just allows everything to run a little bit smoother. And then finally, sometimes there can be a lot of distracting energy or noise or dynamics in the room as well. And I think it's important also to not just try and plow ahead through it, which often doesn't end up working very well, but taking that moment to validate and name that dynamic that's in the room can be helpful. That could be something as simple as in a level one trauma, if we've got a lot of people and they're all having side conversations, and it is too loud to hear the orders, it is too loud to hear that primary survey. Just taking that moment to raise my voice a little bit, not in an angry or shouting way, but in an authoritative way and saying the volume in the room is too high right now. We need to bring it down. And if you are not actively involved in the resuscitation, I need you to take a step back, right? I need you to leave the space. So just taking control of the room in that sense, or maybe there's a dynamic where leadership is unclear between multiple consultants who are all at all at the bedside. And at some point, there might be a situation where you have to take on that role and say, you know what, guys, I'm gonna take over this resuscitation. Here's what we're gonna do next. And particularly in the emergency department, I think that is a really important thing to do because our teams know us and trust us, and it allows us to be much more effective. And we know the context of our clinical practice environment in the OR, that might be you as the anesthetist who's watching the patient's vitals and you're noticing that something is dynamically changed. But whatever it is, taking that time to really validate, name that dynamic in the room, and then outline for your team what are we going to do next.

Resuscitation summaries

SPEAKER_02 55:32

Thank you so much for that. I just had two points I wanted to add on. The first was when you mentioned recapping for the room, I think it's such a really good skill to have. I remember when I was trying to build that in residency, that it felt really awkward in a lot of the simulator sessions where I was like, okay, I think we what we have here is a 37-year-old male, and I was describing essentially a PE or head injury or whatever the situation happened to be. But the first time that I did that as a staff, I remember I had nurses coming up to me and I was like, oh, that was really clear and this was really good. And I was like, oh, I was just doing what I remembered from sim and it felt really artificial, and I really didn't know what benefit it was going to have. And yet people really appreciate that because it's not something that everyone does. It's certainly not something that comes automatically. It's, I think, very much a skill that can absolutely be learned. The second thing I wanted to say was I had a captain that I flew with and he turned to me and said, Adam, I don't have an unuttered thought in my head. And his point was that if there is something going on, I will know about it because he will be talking about it. I don't have to wonder what he is thinking. And there are just people that do this, and whether it's because they trained that way or what have you, it is definitely a mode that they can get into.

SPEAKER_00 56:39

I think to that point, recaps do a couple of different things. They share your mental model with the rest of the team. I think they also help to establish your role as the leader. And I think by doing that, that also makes the rest of your team feel a lot calmer because they feel like someone is in control and we know where we're going next. But I think the moments where it's really helpful in that initial handover. So anytime you have a handover event, a recap is helpful, not only to reestablish roles, but I think to make sure that nothing critical has been missed in that handover. It's helpful in outlining the initial management steps. So typically after I've received that handover, I will recap for the team and then pivot it into here's what our next priorities are going to be to set that direction for the first 10 minutes. It's really helpful before and after any critical procedures. So before and after an intubation, let's take a moment to pause, recap as a team, make sure that we're all dialed in for this critical or high stakes procedure. And then after the procedure's been done, we can reorient for our next set of priorities. And then finally, I think it's particularly helpful when there's a critical status change for the patient. So if somebody notices a critical change in the patient's condition, a change in the rhythm on the monitor, or we've now lost pulses, that requires a rapid direction change of your priorities. And so that's a really good time to recap as well.

SPEAKER_02 58:05

I wholeheartedly agree. It's also a time for me to actually be thinking, as I'm telling the story of what it is, I'm now converting my schema to oh, PE, head injury, what have you. And then I go down my sort of pathway and then I invite some input from other people. It's a time that I can actually catch up myself a little bit, a little bit mentally as well. And I think just the point that in any new skill that you're acquiring, it's going to feel awkward. And I think we have to get over that initial period of feeling awkward in order to really exercise the skill to its maximum benefit.

SPEAKER_01 58:38

I don't want to beat this subject to death, but I feel extremely passionate about recapping things. About several months ago, I was working in a site and there was like a very operative emergency that occurred. And one of the biggest like selling points for recapping is that two nurses independently were talking, and they said, We did not realize we were in a code until 30 minutes in. The physicians actually said, Should we like announce the code to the room? And I'm like, that is a huge red flag, right? Like they were actually doing the kind of recapping in real time, and only then when people had heard like the sequence of events, did they realize like the wheels had fallen so far off the cart. So it happens, and it happens probably more often than you think. And I think as a junior attending, I don't necessarily have all the confidence in the world. And one of the adages I find still holds true is sometimes the nurses who are there for 30 years know more than you will ever know in your time. And so using that to garner knowledge from outside without necessarily denigrating yourself or questioning your skills in a situation where you're thought to be leaders is very useful for recap.

SPEAKER_02 59:29

As Katie already mentioned, which is that she's the holder of the big picture if she's the leader of resuscitation. And in my view, if you're doing your job well, you maintain your situational awareness. And one of the reasons that you do that is you're not heads down, as we would say in the cockpit, or you're not focused on getting that IV, IO access intubation, what have you. But your other colleagues might in fact be doing those things and probably are doing those things. And so perhaps those nurses in your case, Amir, didn't know that they were in a code because they were just so fixated on doing whatever it happened to be. And it's easy as the leader to forget that not everyone has shares your mental model and your view because they don't necessarily have the same information and not because they don't care, but because they were in fact doing their job and doing it quite well. And so I think those recaps have a lot of value that way. The last thing I was gonna say was we work in a lot of different hospitals with a lot of new teams. And sometimes it's not, well, should we call cardiology or what have you? It's that the nurses in the room, especially ones that have been there for 30 years, know the institution like the back of their hand, and they know that the next step isn't call cardiology, it's to call this doctor or in this hospital, it's actually how this works, or this is the number, or whatever it happens to be. The institutional knowledge can save you a ton of time. And as we know, in a crisis, that's incredibly valuable.

SPEAKER_01 1:00:43

If

Escalation of language of concern & assertiveness models

SPEAKER_01 1:00:44

we reflect back on our first couple of episodes where we discussed the Elaine Bromley case, there was a nurse who brought the crate into the room, but this information wasn't acted or done anything with. What can you tell us about effective communication in a crisis, both verbal and nonverbal?

SPEAKER_00 1:00:57

I think when stress is high and when your patient status is critical, you got a really, really sick patient in front of you. Assume that everyone is tunnel visioned to some degree. And communication at the end of the day is a two-way street. You might be the only one who looks at the monitor and notices that rhythm change initially. And you can be the voice in the room that helps to identify that for your team well before the team leader may be paying attention to that particular monitor or that particular finding. So it is part of our jobs as team members also to speak up when we see these things happening. There are multiple different models or frameworks that exist out there. For example, I really like the I notice, I wonder, I worry, this is critical model. And how urgently I escalate my language depends on the urgency of the situation. So if I have a few minutes, I may wake my, I may work my way up that urgency ladder. But if it's critical, then I might just start with, I have a critical finding. Here's a change. And part of that is the verbal phrase that I use. Part of that is the nonverbal stuff that comes with communication as well. So raising my volume so that I can be clearly heard in the room, sometimes even physically raising my hand or where I position myself in the room, sometimes even tapping the leader on the shoulder to get their attention if it's an appropriate moment to do so. But otherwise, in terms of how I might operationalize that language or that escalation language ladder is something along the lines of I noticed that the oxygen sats are starting to drop. Do we want to do anything about that? I wonder if we should insert suggestions. So I wonder if we should turn up the oxygen. I wonder if we should add a non-rebreather. I wonder if we should transition to positive pressure ventilation, maybe try some BIPAP, the next level up from that. I'm worried about the hypoxia. I think that needs to be our priority next. Um, and finally, if I'm now at a point where I need to really take over or where I really need to push the team because we're taking too long, the oxygen levels are critically low. We need to act now. Here's what we need to do, right? If the situation is more urgent, we can borrow from the world of aviation where they use a two-challenge approach in some settings where I will raise a concern. And if I do not receive timely acknowledgement that my concern has been heard by the team lead, I'm going to assume that the team lead either hasn't heard me or they're in cognitive overload. And maybe they've lost situational awareness. So that's the time when I might need to announce that I'm taking control of the situation. Now, how you use those safety escalation skills will depend a little bit on your role in the situation. So you may not be in a position to take over control if you're a medical learner or if you're a nurse or a paramedic who's supporting a resuscitation, for example. But in those situations, you can still identify someone else in the room who might be a reasonable second in command, essentially, who still has some preserved situational awareness that you can then go and reach out to. So that might be a backup physician who is supporting the resuscitation, or maybe even a charge nurse. If you notice that your team lead has lost situational awareness, they're not noticing or reacting to something that's critical, that's where perhaps going to that second in command person can be really helpful. And either they can maybe flag it more effectively, or perhaps they can actually be the one to take over.

SPEAKER_02 1:04:29

If we had the Elaine Broman case reimagined, I'm thinking of some nurses that I work with who are quite assertive and who obviously wouldn't be cutting the neck, but they might take the scalpel or take the crike kit, put it in my hand, or the second surgeon's hand, or whoever it happens to be that they would think would be the person that would cut the neck and say, you need to cut the neck now. Something along those lines, very direct, very specific. And I think that's very hard to ignore as well, as opposed to a nurse bringing the kid in, not getting a response, and then not continuing on with the assertiveness and so on.

SPEAKER_01 1:05:00

I don't think I can summarize any better than you've already done, Kate, but I think it just makes me go back to what you said initially at the beginning, where a lot of this is built on trust, respect, and understanding. So I commend you into that you're able to generate such a high degree of trust and respect with the people, even on a very short notice of time. I think there's something to be said about that. And hopefully at the end, we can go back to talking about how those skills are developed because I don't think they necessarily capture what we're saying now, but it should have some space.

Avoiding task saturation and maintaining situational awareness with complex procedures

SPEAKER_01 1:05:24

All of us work in settings where sometimes we may be delegated to do certain procedures, things like intubations, things like chest tubes, airways, IV starts, cannulation, et cetera. When there's a high crisis, these things can saturate our attention. Katie, any advice on how to mitigate that?

SPEAKER_00 1:05:40

I think a lot of it comes down to recognition and preparation. So I assume that any complex or high stakes procedure is going to be all consuming for my attention. And whoever is doing that procedure, whether it's myself or somebody else, really should only be paying attention to that procedure, to perform. As efficiently and as smoothly as possible. And so if that's a team member, if that's another team member, then I, as team leader, I'm very intentional not to interrupt them until they are finished that procedure, if at all possible, because I do not want them distracted. And then that's where the recaps come into play after that procedure is done to bring the team back online and back up to speed. If I'm actually the one doing the procedure, so say I've flown out and I'm floating a pacemaker, for example, and I know that I am very task saturated, then before I even start the procedure, I specifically delegate situational awareness to the rest of the code for somebody else. So that might be a backup physician colleague, that might be the documenting nurse is often a really good one to maintain situational awareness because they're hands off the patient. But if there's something I need them to remind me of, if there's something I need them to keep an eye on because I'm going to be task-focused, that's really important that I delegate that in advance. A classic example is if I've got a difficult airway where I've got a double setup and I think there's a chance that I might need to cut that neck because I don't know what I'm going to see when I go in with my laryngoscope, I specifically delegate somebody else to watch the SATS and we talk about as a team during our checklist what the criteria will be to pull the trigger on moving to surgical airway. And somebody else is responsible for making that call because I am going to be task saturated with my difficult intubation. So again, whether that's my respiratory therapist, my nursing colleague, my backup physician, I want you to let me know if the SATS drop below 80%. And that's our threshold for us to move ahead with surgical airweight. I will call out what I'm seeing as I'm intubating so that the rest of my team knows what we're dealing with. But I think having that delegation of situational awareness is really important as well. And in the moment, if I suddenly realize that I have lost situational awareness, I've actually seen some team leads do this before when I've been supporting them in resuscitation. They will just say that. They'll say, I've lost situational awareness. Who knows what's going on with XYZ? And then other members of your team have your back and they can jump in with that input as well. So I think all of those pieces can be really helpful. But again, assume that any high stakes or complex procedure is going to be very cognitively overloading. You will get task-oriented, you will get tunnel-visioned. So prepare accordingly.

SPEAKER_02 1:08:34

I love that you mentioned it. It's okay to say, I've lost situational awareness. Please somebody help me up because that is how you get situational awareness back. It's likely to happen to all of us at some point. And it's the expert clinician that admits when they have lost that and regains it. It's not about being perfect, it's about getting to good enough, essentially. We talk a lot about sim training and how that can help us become better leaders and perfect our CRM. It can also help us have a better appreciation when we're doing the non-leadership roles. If I'm playing the role of a nurse, for example, when I'm getting I.O. access, it's one of those things where you go, oh, I did not realize that when this person is doing this task, that they really have no clue what's going on. It's really easy to just lose that picture. And so it then reinforces the idea that when I'm the leader, I'm going to have to include these people, or at least, as you said, you mentioned a number of different things in terms of delegating and not interrupting people and recapping afterwards and so on. If we get in the sim more often, not just as the leader, it'll really bring an appreciation of other people's roles as well.

SPEAKER_00 1:09:37

I think just to expand on that as well, Adam, because I think that's such an important piece for any listeners out there. If you are routinely part of resuscitations, but maybe not in that team leader role, you play an important part of that team leader's situational awareness and that whole team's situational awareness. And it's totally okay for you to ask for recaps if you feel like the team is floundering, we don't know what direction things are in, we're all feeling a little bit nervous about where this resuscitation is going. It's okay to say, can we please have a recap?

SPEAKER_02 1:10:09

And I've certainly had some really cherished nursing colleagues remind me of things from time to time, and not in a pointed way, but saying, Oh, would you like to call cardiology? Or we have a race team or a COT team or any one of these, whatever you want to call it. Each hospital has its own sort of mini resuscitation team. And this actually happened to me. I happened to say, oh, we need more hands because this was an after hours in the PACU resuscitation. I was actually in the operating room with a different patient who was under a general anesthetic for an appendectomy. And then I got called out emergently. Thank goodness it was a smaller hospital across the hallway to the other patient that was in PACU, and they needed an actual resuscitation. And so now my attention is split between two separate patients. I'm the only physician for these two, and now I have to call more hands and so on. And that would have been a great time if I had not realized this for someone to say, Did you want to call the COT team, which is the critical care outreach team? And it's things like that, where I often find that really good nurses will say, Doctor, did you want X, Doctor, did you want to call this team or this specialist, or did you want this type of intervention, BIPAP, what have you? Because often it's them that knows what's going on as well.

SPEAKER_00 1:11:16

I love when team members hand me the solution to the problem I'm facing on a silver platter. That's so helpful.

SPEAKER_02 1:11:23

Katie, you mentioned a few different things in terms of escalation of language of concern, particularly the new resuscitation. You mentioned the two-challenge rule from aviation. I wanted to clarify that a little bit just because that's my initial home profession. It works in aviation in the sense that every time one pilot says something to the other, there is a required response. There is this what we call standard operating procedure. And it might just be somebody calls out airspeed, and it's either the response is either intentional or correcting or what have you. Every single call out, as we say, has a very specific response. And so the absence of response is just not a proper response. That's everything is a challenge. Airspeed requires a correcting or what have you. And if there's no response, the concern might be, well, maybe that person is incapacitated, whether it's a subtle incapacitation or a complete or what have you. And so that's why that two-challenge rule works in that case. And then

PACE model of escalating language of concern

SPEAKER_02 1:12:17

as we also saw in the previous episode, when we're talking to Captain Mike Schuster, the CRM handbook that you mentioned here in medicine does talk about the PACE model. This is the PACE model. It stands for probing, alerting, challenging in emergency. And I have to say that this is again something that I really have to actually practice in order to get down. But the idea is, as with the other I notice, I wonder, I worry, this is a safety issue I'm taking over, very similar escalation of the language of concern. And if something is an absolute emergency, you might start out at that highest level, but you might also start out at the lower level if you have some time. So with the PACE model or PACE model in terms of probing, alerting, challenging, emergency, the probing question might be are you able to effectively oxygenate the patient with an LMA? The alerting might say the patient's oxygenation is 60% and dropping, it's been less than 90% for over two minutes. And that's really where you are alerting the person, you're bringing some new information to their attention. The challenging is to say, we need another method of delivering oxygen. I will get the cricket kit. And then the emergency is here is the cricket, it needs to be used now, or doctors is going to perform a surgical airway. That's how that would look like there. I have to admit that this is something that I would have to practice and do try to practice, as you said, visualizing, but also perhaps in the SIM as well. I was going to leave it there in terms of escalation of language of concern, but if you have more to add on, I think this would be a great time.

SPEAKER_00 1:13:39

Truthfully, I think whatever model that you use, it comes down to actually practicing with that language so that when you actually need to use it in an emergency, it is ready primed in your back pocket. You can pull it out and you're not trying to navigate it for the first time in crisis. So I really like the pace model. I personally use the other model just from personal experience, but I really like the pace model. And I like just having some phrases in your back pocket that you can reach for again in those times of emergency, but really taking the time to practice it. Say it out loud on your own, in your own room, in your office, whatever. Practice it in a sim environment, visualize it, but use those phrases in your mind so that they are familiar to you.

SPEAKER_02 1:14:28

I really think it's something that everyone needs to be familiar with. But in particular, I think the power structure that exists in medicine, we need to make the junior people in the room, we need to empower them and give them permission to use these and actually expect it. And I have a little anecdote here. A few years ago, I was watching Dr. Dave Williams, who is a former not only Canadian astronaut, but before he was an astronaut, he was actually a Sunnybrook emerged physician. And of course, being well versed in aviation from his astronaut days, he went back and he was talking to a group of surgical residents, and I believe this was a group of general surgery residents, and he asked them what they would do if their attending was going to cut the common bile document, which would be a major error and would require the patient to be transferred to a tertiary care center for advanced care. So it's just a major, major error. And several minutes went by before a senior resident in that group said, Well, maybe I would say something like, uh, Sir, can you review the anatomy with me? And obviously at that point, had that been a real emergency or had that been a real surgery, the common bile duct would have already been cut. And the point that Dr. Williams was trying to make was that in other disciplines, there are these set and ready-to-go methods of bringing these concerns up. And as we've tried to illustrate on this podcast, it's the tool that works for you that needs to be used. Whether it's the I notice, I wonder, I worry, I'm taking over, or whether it's the PACE model, it's the tool that works for you. But also the system and hospitals also have a role to play in this. And we have to make it uh okay for our junior people on our team to confront us with this, to use this language. We have to make it explicit, and then we have to train with it in order to actually build it into our practice.

SPEAKER_00 1:16:16

The reason I like the concept of safety escalation language is because it makes the best possible assumption about the other party. You're assuming that they have lost situational awareness. You're not assuming that they're an idiot or they just don't know the anatomy or they don't recognize their own mistakes, because nobody inherently goes in trying to make a mistake. So some piece of the puzzle is missing. Maybe they've lost situational awareness, maybe they're tunnel-visioned, maybe they're distracted, maybe they're really tired because they've been on call for 36 hours. And so the safety escalation language, by starting with probing and alerting, or by starting just by pointing out an objective fact, it allows that situational awareness to come back in a non-confrontational way that feels safe, I think, for both parties involved without that risk of defensiveness or repercussions or any judgment applied to it. And it allows that other person to pick up the ball again and move forward with it safely. And as we move up the safety escalation ladder, I think that's where individuals have to make a decision based on their role, the dynamic at play, whether or not there's a power imbalance or what your individual team and culture are like in your department, what is the next best step to escalate that? And that might look different for you depending on what level of training you're at, what hospital site you're working at, who you're working with. But thinking about this in advance, visualizing it and practicing it in advance will just better equip you for dealing with this in the real world when it comes up. So you're not having to troubleshoot and figure it all out in the moment.

SPEAKER_02 1:18:01

It's a well-made point that I didn't think had to be made. And it's probably because I came from aviation, because when planes crash, uh, you don't need more motivation than saving your own life. And we've looked at this in some of the other episodes that we've talked about. And perhaps it's because it came from there that I just I generally think that people are smart and not trying to be malicious or they're not incompetent or anything like that. And yet I think sometimes in medicine there's this perception that it comes off that way. And so the more neutral language we can use, it really fends off that defensiveness. So it's a well-made point. The other thing that I was gonna say was we look at this, and I think it's important that it does come from places like aviation where pilots have lost their lives, and uh it's one of those things where clearly they are trying very, very hard. And we saw these things in some of the accidents that happened in the 70s, 80s, and 90s, but we also are gonna see this in an accident called First Air, which was a Canadian accident where the first officer was trying to tell the captain and didn't have these skills. So we sometimes use aviation as an example of, oh, well, there might be 50 years ahead. The reality is that they're still learning a lot of this. And when they looked at this at the Transportation Safety Board, one of the big things was the first officer was trying to bring a very clear idea that the mental model has been lost and people's lives are at risk here. And I don't believe that the captain woke up thinking that this was what was going to happen or that he was going to half-ass anything. And I think they were all trying to do their best. And yet this still happened. And one of the comments and findings that the Transportation Safety Board had was we should be training people to use this PACE model and actually build it in so that first officers and other people have these tools so that they can more appropriately assert themselves and then hopefully avoid these situations. And then when I think back to the Elaine Bravley situation and look at the nurses, it's almost guaranteed that they didn't have the tools that this first officer had and that we now have in aviation that we're trying to bring into medicine. And so I really think it's asking a lot. They already brought the trick kit, they already maintained their situational awareness, they brought it in the room, they announced it, they essentially did everything right. They didn't have this tool. But I think Amira made this point before, which is it is a tool. It's not necessarily going to save the day every single time, but it is a tool that is available and we can only use it if we're familiar with it.

Safety escalation language as a professional / soft way of raising a concern and conflict resolution

SPEAKER_00 1:20:24

I think it's also important to mention that when it comes to using safety escalation language or resolving safety concerns in real time. Number one, just like any conflict resolution piece, we talked about the importance of maintaining respect, mutual respect and professionalism. But I think additionally, the more I can offer the other person a graceful off-ramp that allows them to save face, the better the resolution will be. Because then nobody has to feel bad at the end of that interaction or that they made an error or were about to make an error. There's no judgment applied to it. So that's number one. But number two is we talk about these tools, we talk about the training, but I don't want to minimize the fact that this can be very hard in the moment, depending on the power dynamics at play, the human factors at play, the egos in the room. There may actually be real considerations for repercussions for taking action to do the right thing in that moment. And that's a really difficult thing to take on as an individual, especially when you are new in practice, when you're a junior, when you're a trainee, and there are maybe reputational or career-related repercussions that potentially could be on the line. And so again, I think that comes back to where it's so important to think about these moments in advance, visualize where are my thresholds, my boundaries, what strategies can I use, what language can I practice so that I at least am as well equipped as possible to deal with those really difficult situations in the real world.

SPEAKER_02 1:22:07

Extremely well put. So just turning to a summary of some of the key points, we talked about cultivating situation awareness. We talked about the fact that CRM, at least in the medical context, is doing the right thing at the right time, and it requires dynamic decision making, communication skills, coordinated team dynamics, and all of that begins with cultivating situation awareness. We talked about a number of different strategies for that, including scanning the environment for cues, strategies for avoiding fixation error, habits for avoiding stimulus overload, and effectively sharing your mental model. The second thing we talked about was depersonalization and finding common ground, that we should start with the presumption that everyone is doing their best and engaging as you can with them and avoiding personal attacks. The third thing we talked about was validating and naming the dynamic in the room, whether it's overtly labeling it as a challenging dynamic because of the patient population, or validating specific emotions or frustrations up front. We talked about de-escalating the room and a number of different strategies. And then we also looked at synthesizing verbal and nonverbal communication because, as we all know, what you say is only part of how you communicate. Finally, at the very end of this episode, we looked at safety escalation language. And to me, that's the meat of this. We started this podcast series talking about Elaine Bromley and how the nurses brought the Crike kit in, but knew what they what needed to be done in terms of front of neck access, but they just didn't have the language. This is the language that we're talking about. And so I really like the idea that there's a few different models. The I notice, I wonder, I worry, this is a safety issue, or the PACE, which stands for probing, alerting, challenging, emergency. Again, you can use whichever model is actually going to work for you, but it's really the model that you are comfortable with and familiar with. And I would really highlight the fact that Dr. Lin mentioned a few stock phrases to have in your back pocket. Highly, highly, highly useful. Did I miss anything here? Are there things that you wanted to highlight?

SPEAKER_00 1:24:09

I think that's a great recap, Adam. And

Use of simulation to develop and strengthen CRM skills

SPEAKER_00 1:24:12

I think that for anyone out there who maybe you don't have a SIM training program or a CRM curriculum in your own department or in your own training program, it really starts with recognizing the value of CRM training in medicine, makes us much more effective clinicians, team leaders, members of healthcare teams. And really, I think that simulation training is where you get the biggest bang for your buck in practicing a lot of these skills with one another. Not only does it allow you to practice a lot of these skills that are so hard to just read about in textbooks, they really have to be operationalized for you to become fluent with them and at using them as a tool.

EMsimCases.com

SPEAKER_00 1:24:54

But I think it also over time, SIM, especially multidisciplinary SIM, fosters that mutual trust and team building within your department. People often think that one of the barriers to SIM is the financial piece of setting it up, the upfront costs of getting your SIM space and your equipment, but it doesn't have to be expensive. It does not have to be fancy, it does not have to be high fidelity. Even at my center, we've done effective tabletop SIMs where we've just talked through cases and practiced this language, for example. There's also a lot of free open access medical education online resources that you can utilize to start SIM training programs in your own shop. emsimcases.com is a really good example of this, where they've got all these pre-built simulation scenarios. So you don't have to spend a bunch of time building cases or materials. You just have those readily on hand that have already been vetted and developed for you. So just I think wanted to highlight the role that sim can play in being a valuable tool for developing a lot of these CRM skills.

Where CRM may be heading

SPEAKER_01 1:25:59

I'm glad, Katie, you gave us the suggestions of simulation. Again, as alluded to at the beginning, I love sim. You don't have to sell me on sim, but hopefully for people who have not bought into simulation as a concept yet, this is another endorsement. In addition to just expanding the role of sim, are there any other directions that you see this field heading into in the future?

SPEAKER_00 1:26:20

I see virtual care taking on a bigger role in my work, particularly in the pre-hospital transport world, but likely in other areas of emergency medicine and stroke care as well and medicine at large, because we are just seeing that the population size and growth, we're not really matching that in terms of the number of available healthcare providers or resources. So I think we're going to find ourselves increasingly stretched thin. And in order to offer that support to our colleagues who are working in really challenging resource-limited settings in rural and remote places, I think virtual care is a powerful tool that can allow us to extend the reach of expert resource availability and to make sure that our colleagues never feel like they're practicing truly alone. We've already started using some of these tools like video consultation in the Starzair ambulance environment. And it's made a huge difference in terms of being able to provide that timely care in places where it's tough to get transport resources there in a timely fashion otherwise. And so that's one area that I think I can see many of my clinical fields going, but I think it also requires probably dedicated training, knowing how to navigate that virtual care space effectively, especially from a CRM perspective. The things that I do when I'm running a code in person are very different from how I would run a code by a phone call, voice on the line, or virtual care model.

SPEAKER_01 1:28:00

Life or death resuscitation that happens virtually, but having the skills of clear communication, prioritizing, summarizing field will be helpful even when we run into these small issues that can become larger issues because we don't have the ability to see each other face to face.

SPEAKER_00 1:28:14

Yeah, absolutely. I think CRM skills are not just for when the fire is already blazing. I think that it's incredibly effective as a tool before the fire starts at all. And so having those CRM skills just uh again allow us to be more effective as clinicians.

What if we had a non-punitive debrief of every resuscitation?

SPEAKER_02 1:28:33

The question that I wanted to ask you, Katie, was I'm imagining a situation where we look now and we look at aviation and it has six generation CRM and they have all these tools for investigation. If I reimagine medicine and your, for instance, Emerge Resuscitation Bay, and let's say we had an audio video kind of like black box that was in there, how would you feel if we had a non-punitive, non-blame assessment after the fact of a resuscitation that you and your team had gone through and then looked at this from a CRM lens in particular as to how things could be improved? I just wonder how that would hit you. It's obviously not something that we do ever in medicine because we don't even have the tools to do it. But I'm just wondering how you would feel about that.

SPEAKER_00 1:29:20

I think what you're talking about here, Adam, is the debrief part of things and can we utilize that more effectively with the tools that we could implement in clinical practice? And I would personally love that. I know many of my colleagues would as well. But what I would also acknowledge is that it takes time to get to a place where the culture of a department feels safe enough to do that. I think there can be such rich reflection and opportunity for improving your clinical performance and your skills, both individually and as a team, if we had video feed, footage, and expert debriefers who could lead a team through a debrief of a situation or high stakes resuscitation that was really complicated, whether it had a good outcome or a bad one. I think there's still lots and lots to be learned. But again, I think it requires first establishing that foundation of mutual respect and trust so that any debrief activities that we do are done with the right spirit of clinical improvement and mutual respect and acknowledging the human factors part of things. It's not that this outcome was bad because the clinicians were bad and made bad decisions. It's that there were circumstances around this case that did not allow us to perform optimally. Or maybe there are things that we can improve, even if we did perform really, really well. How can we get even better as a team? And again, I think that would be incredible if we could leverage the technology and the expertise around debriefing to do that effectively. I do know that there are a couple of programs in Canada that Toronto, I think, has one where they actually do have video cameras in their sim labs, for example. And so then they can actually look at the video footage as they're doing their debriefs from simulation because simulation is a bit of a safer environment, and you're also not running into any issues with patient identification and confidentiality with that. But it's such a powerful tool for debrief because we know that our memories are flawed, and particularly when we're stressed and cognitively overloaded, that memory really tunnel visions, just like we've been talking about all episodes. So what I recall during a debrief may not actually be what happened. And having a play-by-play for us to then be able to look back on and reflect on would be a super powerful tool. I'd be all for that. Again, as long as we had the right infrastructure for it culturally.

SPEAKER_02 1:31:47

I think that's a very nuanced response. And I think it's completely appropriate considering I've asked you to imagine an alternate universe that doesn't really exist. It doesn't exist in the fact that we don't have the tools right now to have it. Theoretically, you could plunk in the exactly the technology that exists in aviation there, but you don't have the independent investigation for one. And then to your point, you don't necessarily have the trust there because in my mind, we still do very much have perhaps not an overt blame culture, but an unconscious sort of blame mindset to a lot of these things. And then finally, there is this sort of culture in terms of yes, we do debriefs, but that's certainly not the way that we do them. We certainly have never, to my knowledge, had a real-time audio video recording that was by an independent body looked at for the purposes of improving team performance in the future, not for obviously litigation or punitive or anything like that. And it would be very much we're talking about tools that don't currently exist in the healthcare infrastructure. We're talking about investigatory mechanisms that don't really exist at the moment, and we're also talking about a culture shift that would be required in order to have it in there. But I also wonder two things. One is not just the bad outcomes that we could prevent, but the good practices that we could also implement. And this is one of the reasons that we started this, where sometimes we see things that happen in resuscitation and we go, oh, I'm stealing that. I'm gonna use that in the future, whether it's a phrase or an action or a micro skill. I remember one time I happened to see someone, it was a nurse that was uh slickly getting IV access in a resuscitation, and she dabbed her gloved finger on top of a tegaderm so that she could just flip it over and slap it right onto an IV. And I thought, oh, I'm gonna do that in the future for sure. And I absolutely have, but it was just one of the small micro skills like that, and it is curious to know how much faster we could be learning a lot of these things. So thanks very much for that.

Random recommendations

SPEAKER_01 1:33:41

So at the end of our episode, we were inspired by Accrack, the Anesthesia Critical Care podcast for some random recommendations. Katie, I know prior to our episode you had something that you wanted to share. We love to include these. What's something that you would recommend to our listeners to tune into?

SPEAKER_00 1:33:59

Yeah, not really directly CRM related, but definitely human factors and human experience related, I think. I would encourage our listeners to check out a book called The Anthropocene Reviewed by John Green. If you want a moment of thought-provoking calm in your life, which I certainly am seeking that these days. Each chapter features a mini essay that's prompted by regular everyday objects or topics that John then rates on a five-star scale, along with a thoughtful essay that beautifully meanders through the nature of life, hope, resilience, and the human condition. So it is undoubtedly my favorite nonfiction read of all time, and I come back to it all the time when I'm just feeling like I need a little injection of hope in my life. And I particularly enjoy the chapters on Canada Geese, rated two out of five stars. And for those of you who have ever encountered Canada Geese, you probably know why. And Sunsets, which rated five out of five stars.

SPEAKER_01 1:35:00

I'm a big fan of John Green. I know that book moderately well. It's on my tobai list, so I'm glad there's a plug-in. It's not just me plugging the same stuff I like over and over again.

SPEAKER_00 1:35:11

It is so good.

SPEAKER_02 1:35:13

Thanks very much, Dr. Katie Lynn. You've been an absolutely fantastic guest. We will have to have you back on the show because there is so much to unpack from here and so many more places that we can go. So thanks so much for coming on the Medical Safety Podcast.

SPEAKER_00 1:35:26

Thanks for having me. It's been an absolute pleasure getting to explore this topic with both of you, and I would happily come back and nerd out some work.

SPEAKER_01 1:35:34

Awesome. We look forward to it. Take care.

unknown 1:35:37

Thanks.

SPEAKER_01 1:35:38

In the next episode, we'll be talking to one of my mentors and my old program director, Dr. Jesse Goscott, about his research and experience using simulation to teach crisis research management. So, Adam, why don't you give us a safety intervention worth mentioning in the context of what we've been talking about today?

SPEAKER_02 1:35:54

Yeah, the two things I wanted to mention here was one, the CRM handbook, which we'll link in the show notes. And Dr. Katie Lynn mentioned that as well, with her colleagues having initially put that out back in 2017. And then she also mentioned emsimcases.com as a really good resource as well. And so those are the two safety interventions worth mentioning. On a who can do what tomorrow morning, in terms of policymakers, regulators, medical schools. We talked about the fact that CRM right now is sort of a those who are interested, or if you happen to have it in your curriculum. And so those policymakers, regulators, medical schools could mandate CRM training in med schools, residencies, CME with a more sort of rigorous style. And then they could also implement, for example, some kind of more aviation style investigation, as we've seen in other countries, where they look at critical incidents, but they also look at the actual human factors aspects to them and what CRM might do to mitigate those things. They could also pass legislation requiring OR black boxes, but we saw that while we have the tools, there is a lot that has to go into it before those things can be done. And then in terms of hospital CEOs, we talked about the fact that they can require safety investigations to consider human factors and CRM factors, and in particular, empowering nurses and other hospital personnel to use the language of concern without fear of sanctions. If you're a department head, you could provide CRM training, and we saw in episode three with Mike Schuster about the fact that the latest generation of CRM in aviation is a company specific with realistic training. And you can imagine that there would be scenarios where specific hospitals may have had certain incidents or maybe more at risk of some things rather than others, and they could train with those in mind. And then finally, if you're a practitioner, I think Dr. Cady Lynn gave a number of different interventions that can help, even if you don't have access to a high fidelity SIM lab or a low fidelity SIM lab or a residency program that has this, or CME, for example. We talked about reading the CRM handbook, visualization, having those specific phrases in your back pocket to use, and then practicing recaps to improve situational awareness and then mitigating fixation by delegating those tasks, like we've talked about. Amir, anything I'm missing here?

SPEAKER_01 1:38:08

No, I think the one thing I'm taking away is still practicing those phrases, is still the visualization. I think I've taken for granted how many of these experiences I've had where I've been able to apply them, but the number isn't so large that I get to practice them routinely. So I'm certainly going to go back for myself and be a little bit conscious about what I would say and what I would do and really put myself in the position visually or imaginatively that Dr. Lin suggested to hopefully get a higher fidelity in the lowest fidelity setting possible.

SPEAKER_02 1:38:38

Well, moving on to the fun suggestions and random recommendations, like uh Akrak, one of our favorite podcasts. I had recently had a chance to check out just something called Exit the Game, which is a tabletop escape room, sort of fun for all ages. Uh Amir, do you have anything for this?

SPEAKER_01 1:38:54

I'm just gonna piggyback off Exit the Game. So it's an escape room that you kind of go through. And Adam, I'm glad you gave it a try because me and three other people of what I would say at least average intelligence, we struggled so hard. We scored the lowest possible score. We could not get out of this setting that was supported. So I'm actually gonna recommend an alternative podcast. I'm gonna recommend the podcast 99% invisible. It's a long-running podcast. Why I picked this one today is that it is a design-focused podcast, and there's a handful of episodes that are really well recommended and well-reviewed, and I'll put maybe my top two or three in the link or the description of the show. But it has certainly opened my eyes to design-based principles and how to approach a problem with an iterative improvement mentality. This isn't necessarily the same thing as the quality improvement thing that we talk about in medicine. It's very much like, hey, when we're trying to build something, how do we go to the stakeholders, get feedback, iterate, and get feedback again? It's not something that I'm well versed, or I think medicine talks about a lot, but it's super, super applicable to projects, tasks, teamwork that you want to get off the ground, and it gives you a better way to communicate troubleshooting and improvement going forward.

SPEAKER_02 1:40:08

Okay, and that's it for this episode of the Medical Safety Podcast. For our guest, Dr. Katie Lynn, I'm Adam Shahada.

SPEAKER_01 1:40:15

And I'm Amir Hammond, and we'll talk to you guys next time. Or as Adam likes to say, I'm gonna keep peggling this to you, Adam. I don't want anyone to assume that I'm the one who puts these in the episodes, but as one TV doctor said, What?

SPEAKER_00 1:40:30

You have to say it.

SPEAKER_01 1:40:34

Beautiful day to say by following us on all the socials. You've heard them before, you'll see them again. Adam will add them in. We look forward to having you join us next time.

SPEAKER_02 1:40:45

We are looking for an intern to help do research and make show notes for this show, as well as a producer to help with technical aspects such as mixing and editing. As this podcast currently receives no outside funding, these would start as volunteer positions, but hopefully, if enough people are interested and donate, it may become a funded position. This would be a great opportunity for medical students, residents, or other people that are interested in patient safety, critical care, anesthesia, or aviation. If you are a fan of the show, please consider going to wherever you got this podcast and leaving us a positive review. It really helps other people find the show and everyone can learn from your comments. If you are interested in becoming a supporter of the show, please consider going to patreon.com where you can become a patron of the show. Even if it's just a dollar or two, it makes a big difference and we really appreciate it. We'd like to send along a big, big thanks to those of you who are already supporters of the show. Remember, lives are not just saved in the resuscitation bay, countless more lives are saved by the diseases and errors that are prevented and by the work done by scientists, labs, clinicians, and professionals like you working to make every day safer than the last. Thanks very much.