This post is the second in a series recording my reflections on the past twelve months, which I have spent working for Sydney HEMS in prehospital and retrieval medicine. The first post covers medical education – you can find it here.
This post covers some of the things I have reflected on relating particularly to human factors. Like many reflections, they’re not necessarily new things I’ve learned but rather concepts I’ve had cause to revisit (or wished I’d called to mind more quickly in the heat of the moment!). The aviation industry has a long history of understanding human factors and following the tremendous work by Martin Bromiley, many clinicians have drawn parallels between error rates in medicine and aviation (including astronautics) and the things we can do to fix them. Of course, there are differences between these industries too (Scott W and I once had a chat about how perhaps we should be looking at air traffic controllers as a better surrogate for EM clinicians – if you’re interested, read this, this and this), but there are also differences between EM and radiology – that doesn’t mean we can’t learn from our colleagues.
Part Two – Human Factors
Using people’s names really helps get things done
I have a good memory, but I consider myself pretty awful at remembering people’s names. I’ve made a real effort to try harder on jobs this year and it has been really effective. Some of the work we have undertaken has involved travelling to very small hospitals and healthcare facilities where staff are often overwhelmed by the demands on them – we are usually there to retrieve the sickest patient they have, sometimes the sickest patient they’ve ever had. Adopting them into our team is key to getting the job done – the wonderful Geoff Healy advocates hard for this as a “hearts and minds” approach. One of the quickest ways to build a rapport is to use someone’s name. It also helps them to focus on the task in hand.
Say thank you
Showing gratitude is the natural extension of the point above. Sometimes we arrive to find that patients haven’t quite had the care we think they should or could have had. We need to believe that people have done their best in the circumstances we found them in. It’s a great rule for healthcare in general. There’s enough backbiting and animosity in the world 🙂
Introducing yourself helps too!
Since the worldwide campaign #HelloMyNameIs was started by the late Kate Granger I like to think we have gotten better at this. It’s important in prehospital care just like anywhere else – it helps with the rapid rapport building mentioned above particularly as teams are sometimes met with hostility (it’s rare but it happens – not everyone wants our input, nor needs it!) – I think it’s a lot harder to maintain hostility when you know someone by their first name.
It doesn’t take long to articulate a plan and your thinking
Sharing your mental model can make a huge difference and will make it easier to get others onside. It can be as simple as outlining your priorities (“our priority is to secure the airway and then transport the patient to the nearest trauma centre”) or dividing steps to get you there more quickly (“this patient will need to be intubated before we can move her, so while we get the kit ready could you secure some IV access? We’ll need that to give the drugs.”)
Under stress, sometimes EVERYONE wants to help
And sometimes EVERYONE wants to stand back. Be prepared for that. Just because you’ve articulated your priorities doesn’t mean the team will magically make them happen! You might need to specifically manage the team to get things done (“we need to carry this patient over there to perform the RSI; can you five take a handhold each on this scoop so we can get moving?”)
You can learn to recognise when other people’s brains are working hard
And maxed out brains don’t take new information on as you hope they are going to. This is particularly obvious during the early phases of our tasking; during one of our education days Sam Immens (paramedic extraordinaire) facilitated an exercise exploring what each member of the aeromedical crew was considering in the pre-launch phase.
You don’t need to be able to read or understand every word on the whiteboard to appreciate that there are a lot of mental processes underway.
So what do we do in that situation? It’s a good idea to sit down, shut up and do as you’re told in those circumstances UNLESS you have pertinent emergency information. This might not come naturally to Emergency Physicians, particularly senior ones who are used to being the leader and the centre of attention, but if I can learn to do it you can too!
Checklists are better than busy brains
Pilots use printed checklists before engine startup, before takeoff, after takeoff, during cruise, before landing, after landing – it’s ok to look at one! High risk stuff is worth the time to get things right. Not everything needs a checklist, of course. But for every single RSI I have done with the service, the checklist has been out and has prompted us to think of something we might otherwise have omitted.
When team members seem hesitant to undertake a particular course of action, it may be a reflection of their experiences in unfamiliar environments – it’s normal, but you can help. Asking if people are “happy” with a plan might get you an affirmative response but it might not mean they are comfortable with what’s involved. People will agree to undertake tasks but not actually be able to complete them – when working with teams with whom you are not normally familiar, you can learn to spot the telltale signs of someone in this position. This might turn into a teaching opportunity or it might prompt you to reassign both the person and the task more appropriately.
Working together under stress builds respect
Working together under stressful circumstances teaches you to really respect your colleagues. Have I mentioned how amazing the paramedics are?! The pilots and aircrew are just as amazing. Seeing your colleagues rapidly prioritise safe decisions – especially decisions about YOUR safety – rapidly grows respect. It’s worth taking the time to think about the individuals you are working with and how they are contributing to the work you do. Everyone is a vital piece of the puzzle. A conscious decision to recognise value that will affect your demeanour towards that person.
Seriously, don’t be rude
On one particular job, I was in the wonderful position of having a hospital consultant swearing at me down the phone. He disagreed with decisions that had been made quite separately from our service and his reaction was to take it out on me.
Take it from me as someone who used to be really, really moody at work (I have been working very hard on this and I think I’m better – if you have feedback for me on this from the last 12 months, I’d love to hear it!): making people feel like crap doesn’t make you feel better. You’ll think it will, but it won’t. And it’ll pretty much make everything get worse from there on in. Lots more thoughts on rudeness here.
Moods are contagious
But you get to decide how other people’s rudeness affects you. You don’t need to be effusively positive all the time (it will be annoying to some people) but there’s a difference between pessimism and realism – frame your day well. Get into that zen state – crap is going to happen today. You get to decide how it affects you, and how it affects you will have ripple effects into your team. Let it go…
If you don’t know – ask!
I mean, it’s obvious, right? But we can waste a lot of time trying to sort things out when asking someone to help you – and to teach you to do it yourself next time – can be far more efficient.
Screwing things up is a great learning experience
But only make mistakes you’ve never made before 🙂
Be vigilant to changes to routine
Know that when your thought processes are disrupted, error can occur. On a particular job, I forgot to do something important before we left base because I was distracted during my preparation for the job by consideration of the weather I’d be facing (I had put an extra warm layer on, then decided it was unnecessary and took it off again. This totally disrupted my preparation processes and I left out a key task).
When you screw up, be honest
It’s weird, I have this little immediate instinct to hide my unbelievable stupidity when I notice it. It’s a natural instinct, but it’s not helpful. We need to work to overcome it and to expose our inadequacy. It’ll help make sure it doesn’t happen again and you may expose some underlying systemic issues (or your own fatigue). When I realised I’d forgotten the important preparation step I told my crew. I felt like an idiot but it was important to share the awareness and come up with a backup plan.
Futureproof your documentation
We can forget that when we are reviewing cases there is often much, much more information available after the event and this can mean that situations are judged in a way that may feel uncomfortable. Vision through the retrospectoscope is 6/6 (or 20/20 for our US colleagues). Be prepared for this – articulate and document your decision processes. It helps you to be able to justify them when needed.
Check your own lenses
But be kind. Remember when your colleagues tell you about a difficult job that you weren’t there. You don’t know what decisions you would have made under the same circumstances – you can only theorise and hope. Make conscious decisions to abandon your assumptions, to aim for understanding and to guard against blanket statements such as “I would NEVER have done that” or “well, obviously you should have…” These statements are not only unhelpful, they can be actively harmful to practitioners coping with trauma. There are better ways to have constructive discussions about how things could be done differently.
I’ve seen great examples of this in this service – in co-ordinating the clinical governance day with my colleague Alan Laverty we wanted to encourage our teams to present their difficult cases stage by stage, opening the decision points up for group discussion before moving on to an explanation of what the team did and why. You might think this would be terrifying and in doing this you would open yourself up to criticism – but the overwhelming experience of presenting teams was that they felt supported and the response from the other practitioners attending was one of respect. It has been a really successful way to draw out learning points.
Watch your fatigue
Fatigue management is a huge issue in aviation. Thanks to champions like Mike Farquhar we are seeing a greater awareness of the importance of sleep hygiene and shiftwork in the NHS (you can read Mike’s recent Fifteen Minute Consultation on managing shiftwork in ADC E&P here – not FOAM)
Being tired leads to errors. If your fatigue is unavoidable, use your team members to help maintain vigilance. Be honest about where your brain is! More resources from St Emlyn’s on this here and here.
Self talk works – for you, and for everyone else too
Telling someone else that everything is under control can help you believe it (as I learned reassuring my patient halfway through a 250ft winch extraction). The winch takes quite a long time when there is such a long way to go up – and halfway through (despite having explained it would take a while before we connected to the winch hook), the patient in question obviously became a little disconcerted about still being apparently in midair, strapped into a winch basket. I saw him lift his head up to look around – so instinctively I shouted “everything is fine, we’re nearly there” even though I had noticed just moments before that both the ground and helicopter seemed a long way away in opposite directions. And immediately he lay down and I felt better too.
We can self-talk in our heads but sometimes it helps to do it out loud. Whenever I am assisting someone with an RSI I regularly tell them “sats are 99%, everything is fine, you’ve got plenty of time.” It’s stressful doing the RSI and it’s stressful watching – we can take control of some of those thoughts with a few simple words and in doing so increase our bandwidth to focus on the stuff that matters.
Put humanity back into telephone calls
There’s a particularly Australian trait I have noticed during telephone conversations. In the UK if you are calling a hospital to be put through to a ward, as soon as switchboard answers you ask to be put through to the ward – simple. This isn’t how it works down under.
Answering person: Hello, St Emlyn’s Hospital, Steve speaking
Me: Hi, my name is Natalie, I’m one of the doctors from the rescue helicopter medical team, how are you going today?
Steve: I’m well thanks, how are you going?
Me: Good thanks, not too busy so far! I was wondering if you could…
At first I didn’t do this (but callers did it to me, when the roles were reversed). Then I heard the paramedics doing it (and I’ve spoken to Brits working outside healthcare – I’m assured the same thing happens there too). My initial instinct was that this was a WASTE OF TIME. But I have reconsidered. Seriously. It’s nice. It’s polite. It’s courteous, and there’s not enough courtesy about these days. Taking the time to ask people how they are builds bridges (and you’re more likely to get what you want!). Try it. Let’s see if we can make it a British thing too.
Coming soon: Clinical Retrieval Medicine and Critical Care
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