Educating Resuscitators: Seeking Conscious Competence

Transcription

1 Educating Resuscitators: Seeking Conscious Competence Peter Brindley MD FRCPC FRCP-Edin Clinical Intensivist and proud of it Other Stuff: Professor, CCM, UofA Adjunct Professor, Ethics Adjunct Professor, Anesthesia Division of Critical Care Medicine

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3 Resuscitation circa 1780

4 Resuscitation circa 1970s Sophisticated intensive care often becomes unnecessarily expensive terminal care when the pre-icu system fails Peter Safar 1974

5 Resuscitation circa 2014 Impending collapse Vulnerable patient

6 ICU Competencies: Resuscitation Diagnosis Disease Management Procedures Perioperative-Care Comfort and recovery End of Life Care Paediatrics Transport Safety Professionalism

7 How do we learn/teach KNOW, but takes effort Often GOOD TEACHERS DON T KNOW but aware Often GOOD LEARNERS KNOW, but not always why Not always good teachers DON T KNOW & aren t aware Not always good learners Noel Burch/Gordon Training Inst

8 Every system produces results that it is designed to Accidental Curriculum : what do we teach? Accidental Competence : how do we teach?

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11 Accidental Curriculum Aron D Safety data not widely shared We don t know if what we teach works Rely upon random presentation Train, educate or simulate Aron D. Qual Saf Health Care 2002 Brindley Crit Care 2010

12 What competence is most important in patient safety? A.Factual Knowledge? B.Procedural dexterity? C.Communication/team skills?

13 Errors in Medicine Human factors > 80% Communication/teamwork >70% Gaba DM, et al. Crisis Management in Anesthesiology St Pierre et al. Crisis Management in Acute Care Settings.2008 Sutcliffe KM. Acad Emerg Med 2004 Khan FA et al. Anesthesia 2001 Brindley Critical Care 2011; J Crit Care 2011 Etc, Etc, Etc

14 Meant is not said Avoid mitigating language Said is not heard SBAR 5 levels of advocacy Heard is not understood Close the loop Repeat back method Understood is not done Verbal dexterity Brindley and Reynolds J Crit Care 2011 Rall and Gaba 2007

15 Skate to where the puck will be

16 Errors of planning, not execution Never let an aircraft take you somewhere your brain didn t already go fly ahead of the plane Ron Coley, US Marines Failure to plan= plan to fail Shared mental model Give your team advanced permission Airway: verbalize a plan A,B,C berkeley.edu/news/berkeleyan/1998/0225/coley.html

17 Athletic Cognitive Preparation

18 Medical Cognitive Preparation

19 Superior to additional practical training Supplements (doesn t replace) training Early evidence for CRM imagery Mental Training in Surgical Education: Randomized Controlled Trial. Immenroth et al 2007; 245 (3) N=98 Chris Hicks, UofT (with permission)

20 Motion Capture: Novice Expert J Carlson, UPMC

21 Motion Capture: in Golf

22 Motion Capture: in Medicine Dr J Carlson, UPMC With permission

23 Where does med education start? 2 seasons 41 intubation attempts Zero correctly positioned Brindley and Needham Resuscitation 2009

24 Airway Positioning Flex lower c-spine Extend OA joint Sniffing pos n 1936 Magill Ears in front of sternum Brindley et al. BJA 2010

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26 Really?

27 Win with the chin: An alternative to the sniffing position for teaching airway intubation Brindley. Resuscitation 2008

28 Any Evidence? Anatomic 37% correct Sniff.15% correct Win with Chin 43% correct Control 20% correct Win with Chin significantly better than sniff Sniff worse than no instructions!! Brindley et al. BJA 2010

29 MJA 2009 Least recorded BUT most specific predictor of cardiac arrest and unplanned ICU Pulse-ox not a replacement Education priority!? Conscious competence S Finfer- with permission

30 Preparing for complexity A physician is a healthcare worker authorized to work outside of guidelines Prof Julian Bion, personal comm

31 Teaching complexity? SIMPLE COMPLICATED COMPLEX EXAMPLE Bake Cake Fly to moon Raise child PREDICTABILITY High Medium Low PERSONNEL Solo Team Team/Community EDUCATION Learn & Practice Break into steps? STRATEGIES Task trainer Simulation Experience Zimmermann and Gloubermann A Gawande. Checklist Manifesto

32 Simulation 1.0 WHY WHY HOW WHAT

33 Simulation 2.0 : five insights Inefficient for t ching v-efficient way to learn More than training/education patient safety lab Experiential, reflective deliberate Social justice imperative hygiene imperative? Address human factors personality;teams;culture Brindley P.G. Crit Care 2010; De Gara C, Brindley P.G C.J.Surg 2012 St Pierre 2008; A Ziv (personal corresp)

34 Basics of Competence Simulation speeds acquisition Performance facts skills behaviours Simulation decreases decay Experience/time

35 Fight; Flight or Freeze Automatic: Cognitively embedded Near Immediate Simple Decisions More than one possible response available Choosing takes few seconds Complex decisions No appropriate response embedded, Response has to be created : many seconds Inability to make decisions Nothing embedded No temporary schema can be created Competent SIM Incompetent Leach J, Aviat Space Environ Med 2004

36 And Finally, let s re-grow a pair Yerkes RM, Dodson JD. J Comp Neurol and Psychol. 1908

37 Questions, Comments? Schopenhauer All truth passes through three stages: First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident. P Brindley Crit Care 2010