Paramedics work in a an extremely unique clinical environment. We’re tasked with working in small ad-hoc teams, we’re required to make decisions that can have significant impacts on patient outcomes, and all of this often occurs in novel environments with many external stressors – making these decisions that much more difficult.
Join Will Johnston and Zach in part two of this exciting podcast as they discuss how to calm the chaos and build highly competent teams to improve patient care.
Will has a keen interest in paramedic driven research, and collective competence and performance in ad-hoc clinic teams.
He can be followed on Twitter @seewillyj
Show notes created by Will Johnston
The opportunity to practice within your team or incorporate stress exposure therapy may be limited especially if you work with different partners often. But there are other easier ways to develop a shared mental model with a team “on the fly”.
One easy way that Hicks (@HumanFact0rz) and Petrosniak (@petrosoniak), two emergency medicine physicians from Toronto, suggest is a simple team “pre-briefing”.
Although they initially designed it for trauma activations in the emergency department it can be easily adapted to the pre-hospital world as well.
The pre-brief consists of asking and discussing four questions, this can easily be established as we are enroute to the call:
- What do we know: this is a quick summary of the information that we have received. Often this will be the dispatch details and may be very basic. For example we are responding to a motor-cycle vs car, the driver of the motorcycle is reported as unconscious and we have fluids on the road.
- What do we expect: what kind of injuries can we expect and how will we respond to them. We have possible pelvic injuries, likely head injuries, the possibility of significant chest trauma. Likely a multi-system trauma. We should think about binding the pelvis, rapid extrication, going to a trauma center, etc.
- What will change: this is our plan B. Consider some other possibilities that we could encounter. This allows us to remain flexible mentally. We can also consider triggers that would cause us to deviate from our initial plan. For example if the patient is in cardiac arrest or has a significant airway obstruction.
- What are our roles: given what we expect to need to accomplish assign roles. For example you focus on binding the pelvis and I’ll work on the airway. Or even as simple as I’ll cut and expose while you work on assessing the patient.
The pre-brief helps to get our team on the same page and develop a shared mental model. By understanding what we expect not only of the situation but each other we are able to collectively improvise better. It is important to note that we need to continue to update our team and share findings so that we can maintain a shared mental model.
Zero Point Survey
One framework for where and how to incorporate pre-briefing for emergency calls is the Zero Point Survey.
The zero point survey outlines the steps we should take to optimize our performance prior to shifting to the primary survey.
Using the Mnemonic STEP UP the zero point survey suggests the following steps:
S – we should ensure that we are ready both physically and cognitively. The physical needs are addressed using I’M Safe Acronym. Illness, medications, stress, alcohol, fatigue, eating and elimination. Not all of these needs are appropriate to address on our way to the call but sometimes marginal gains like drinking some water and having a snack can help improve our performance.
Our cognitive needs can be addressed using the Beat the Stress Fool techniques we previously discussed.
T – addresses the needs of our team. At this point we can complete the team pre-brief to begin to develop a shared mental model.
E – reminds us to optimize our environment as best we can. This includes moving a patient for better access and addressing things like lighting, noise, danger, and crowds. By optimizing the environment we can minimize the impact of this extra noise on our cognitive loads.
After we have addressed the S – T – and E we can move on to addressing our patient with the
P – primary survey as usual followed by
U – updating our team as to what we’ve found and have done. This helps us continually develop our mental model and then as a team set and update our
P – priorities. What needs to accomplish
The authors of the zero point survey suggest that we should repeat the zero point survey whenever we have a change or uncertainty in our resuscitation. This would be similar to reassessing the ABCs as our patient’s condition changes.
In addition to pre-briefing and sharing mental models. To ensure success during a pressure moment we need to communicate effectively.
To do this we need to use and practice with a common language. The way that we communicate during complex situations can significantly impact how we perform as a team. Communication is complex and deserves a larger discussion but there are a few easy techniques that can improve our performance.
When we are in situations of increased pressure we have a tendency to dry and downplay or minimize the meaning or assertiveness of what is being said. This is especially common when there are real or perceived hierarchies.
Phrases like “could someone” or “would you mind” can lead to communication and task breakdown. Concise and direct communication with our colleagues and partners can lead to better outcomes. “Jaimie go and get the scoop stretcher” and “We are going to move the patient to the ambulance now”. There is some evidence for assertiveness training, which focuses on clear and concise communication while downplaying hierarchies being effective at improving our crisis communication.
Closed Loop Communication
Another way we can improve our common language is using closed loop communication.
Closing the loop in this context involves three stages
- A request – Sam administer 0.5mg of epinephrine
- Acknowledgement or clarification – Ok I am administering 0.5mg of epinephrine
- And an acknowledgement when it is completed – The epinephrine has been administered
By using closed loop communication we are able to cross monitor each other to ensure that actions are being performed correctly. If Sam believed that the patient required less epinephrine she would be able to clarify at this stage before it was administered.
Using and sharing a common language allows us to continually update our mental model and keep our team performing together.
We often defer to whoever we think is the most important/responsible/senior person, even if that’s not the right person. Graded assertiveness helps us get around that.
CUS words allow for that graded assertiveness and the ability to challenge some of these situations, especially when working with people you may not be comfortable with.
C – I’m CONCERNED.
U – I’m UNCOMFORTABLE
S – SAFETY CONCERN. In this case, we should stop whatever we’re doing.
We’ve outlined some things that that we can do before and during a pressure moment to enhance our team’s performance but there are large gains that we can make after an event. A teams collective competence develops over time and our mental models don’t just develop during an event. One often neglected area where we can make improvements is in the “post mission” or post call debrief.
Debriefing allows for a double loop of learning. Not only do we reconstruct a full mental image of each team member’s actions and behaviours but we are able to identify what went well, what went wrong, and how we could do things differently to improve care in the future. These discussions add to our mental model and give us more to draw on in future similar situations.
We can use debriefing to make system wide impacts by identifying latent safety threats to both providers and patients. These can be used to design simulation scripts for future training and identify changes that need to be made to the system to better help our patient’s.
But these lessons are only beneficial if they are shared. We should share our lessons learned with our colleagues so that they can be part of the discussion as well. By learning from experience of our colleagues we can build our stock of knowledge for when we face a similar situation.
And, most importantly our post-event briefing should celebrate our successes. The learning from excellence model suggests that we should shift our focus from examining errors in care to celebrating successes. A learning from excellence model that provided and shared feedback on “excellence” and “positive deviance” in a Pediatric intensive care unit, found that staff performed significantly better in the targeted areas and had increased morale. Championing our successes in these cases can be just as beneficial as learning from our mistakes.
Prehospital Care isn’t just Paramedics.
Training pre-hospital teams to work effectively together can be challenging given that these teams are typically created in an ad-hoc manner. If we think back to the case study at the beginning the team of paramedics, firefighters, police officers, and possibly flight paramedics will likely not have met each other before. They have different language and likely a different mental model of what needs to happen to maximize the care for this patient.
In an ideal world we would run interagency simulation exercises that focus not only on the large scale events we typically practice. But also on the day to day calls that we attend. Practicing and debriefing together would allow us to better understand the mental model that our colleagues from other agencies have and better predict and adapt to their needs.
One possible way to improve how we work together would be to debrief with our all of our colleagues after a call with a focus on what went well and what could be improved from each team members area.
If we get to know what each aspect of the team needs we can find process improvements that will make our patient care even better.