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
Resuscitation circa 1780
Resuscitation circa 1970s Sophisticated intensive care often becomes unnecessarily expensive terminal care when the pre-icu system fails Peter Safar 1974
Resuscitation circa 2014 Impending collapse Vulnerable patient
ICU Competencies: Resuscitation Diagnosis Disease Management Procedures Perioperative-Care Comfort and recovery End of Life Care Paediatrics Transport Safety Professionalism
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
Every system produces results that it is designed to Accidental Curriculum : what do we teach? Accidental Competence : how do we teach?
Accidental Curriculum Aron D. 2002 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
What competence is most important in patient safety? A.Factual Knowledge? B.Procedural dexterity? C.Communication/team skills?
Errors in Medicine Human factors > 80% Communication/teamwork >70% Gaba DM, et al. Crisis Management in Anesthesiology. 1994 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
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
Skate to where the puck will be
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 www.skygod.com/quotes
Athletic Cognitive Preparation
Medical Cognitive Preparation
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) 385-391. N=98 Chris Hicks, UofT (with permission)
Motion Capture: Novice Expert J Carlson, UPMC
Motion Capture: in Golf
Motion Capture: in Medicine Dr J Carlson, UPMC With permission
Where does med education start? 2 seasons 41 intubation attempts Zero correctly positioned Brindley and Needham Resuscitation 2009
Airway Positioning Flex lower c-spine Extend OA joint Sniffing pos n 1936 Magill Ears in front of sternum Brindley et al. BJA 2010
Really?
Win with the chin: An alternative to the sniffing position for teaching airway intubation Brindley. Resuscitation 2008
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
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
Preparing for complexity A physician is a healthcare worker authorized to work outside of guidelines Prof Julian Bion, personal comm
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
Simulation 1.0 WHY WHY HOW WHAT
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)
Basics of Competence Simulation speeds acquisition Performance facts skills behaviours Simulation decreases decay Experience/time
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
And Finally, let s re-grow a pair Yerkes RM, Dodson JD. J Comp Neurol and Psychol. 1908
Questions, Comments? Schopenhauer 1788-1860 All truth passes through three stages: First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident. peter.brindley@albertahealthservices.ca P Brindley Crit Care 2010