Bringing the Outdoor Classroom Indoors – #MedEd at #smaccFORCE #smaccDUB

taking the outdoor classroom-2

Before February this year I had no prehospital experience whatsoever – so standing up in front of a crowd at the smacc prehospital workshop #smaccFORCE, I felt like a bit of an impostor. But I get why people love prehospital medicine – it’s kinda sexy. There are helicopters,

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…Helicopters…

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And, yes, sometimes even helicopters in slow motion.

But I’m not a prehospital specialist and it’s time I confessed: I don’t love helicopters. When I applied for this job I was very uncomfortable practising medicine outside a hospital and I was scared of flying.

So why did I want to work with Sydney HEMS? Well, I’m a self-confessed medical education geek and Sydney HEMS has a reputation internationally. The learning environment appears to be one of which clinicians – and I’m talking about senior clinicians – want to be a part.

I wanted to experience the education first-hand, to understand how you can teach an experienced clinician to apply their skills and knowledge as part of a small team in an unfamiliar, unpredictable and potentially dangerous environment? As an educator, that interests me – because that is how many of our junior doctors see the Emergency Department.

I’ve been thinking about three discrete aspects of my experiences so far; induction, competence, and culture. I want us to think about how we approach these elements in hospital, to take you through a brief explanation of the Sydney HEMS approach, some educational theory around why they might work and to think about what we can take from them into the hospital environment.

Induction

Firstly, induction. Have a think about new doctor induction in your department. Do you have one? What sort of things does it include? The last departmental induction I went to as a junior doctor consisted of “here are our protocols, here’s how you use the blood gas machine, now go and do three hours of computer training.”

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Doctors new to Sydney HEMS spend a week training alongside paramedics, learning to contextualise their existing clinical knowledge for the prehospital environment and also to refresh or introduce unfamiliar life, limb and sight-saving procedures. The week consists of blended demonstration, simulation, discussion, debrief and finally an “exam” in which smaller teams work together to meet various challenges which might realistically confront them in prehospital practice.Surgical Airway

The induction training also emphasises human factors and includes stress exposure training – here I am performing a simulated surgical airway, in a simulated nightclub.

So what works about induction?

Bloom suggested that learning should cross multiple domains and induction training does this – teaching and learning addresses knowledge, attitude and skills in combination.

Training doctors and paramedics builds a community of practice, described by Lave and Wenger as a group of people who learn together, sharing a repertoire of experiences, hacks, tools and stories, engaging in mutual learning through discussion and joint activity, in pursuit of a common aim (the provision of better prehospital care to patients).

Social constructivism has perhaps the most intimidating name of all major education theories but it’s actually really simple. The idea is this: adult learners have experiences, and when you put them in groups they will challenge each other’s experiences and thought processes, then go away and make changes to their own perceptions. In order for it to work, the learners have to feel that they are all equal, something we call the flattened hierarchy, so that they can speak freely but value each other’s contributions.

The Sydney HEMS team-based training feeds into this, particularly because it affords us the opportunity to learn from the tremendous wisdom, skills and experience that our amazing paramedic colleagues bring to the service.

Maslow’s hierarchy of needs describes how learners require a sense of belonging to flourish; smaller team training feeds this camaraderie. Why does that matter?

It matters because I need to trust my team implicitly, in situations which are inherently uncomfortable; environments which pose risk to the whole team.

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Image courtesy of Laszlo Hetzman

Including this helicopter underwater escape training exercise (you seatbelt yourself into the rig and it dumps you upside down in a swimming pool whereupon you follow an emergency escape drill – upside down, underwater), of which I was utterly terrified but had to be wholeheartedly trusting of my dive-trained paramedic colleagues to rescue me if I got into difficulty.

So how can we take this into the hospital learning environment? Well, let’s remember that junior doctors new to the ED or ICU also need to form powerful, dependent working relationships with brand new teams; assimilate new clinical information or restructure existing knowledge in a new context, and work out the stresses of an unfamiliar physical environment. We can design induction for our junior doctors to safely mould these experiences and, crucially, factor in debrief to allow higher thinking and processing to occur separately from the stresses of an actual clinical encounter.

What does your department’s new doctor induction look like? Have you considered their non-clinical needs, as well as the clinical? Could you be more holistic in training your team?

Competence

How do you know your colleagues are competent? Do you rely on 4-yearly APLS and ATLS certification? How much value does that hold in the heat of a difficult resuscitation case?

smaccFORCEThere are a number of practices central to PHEM in which my colleagues and I are required to demonstrate competence (we refer to this as currency, a term borrowed from aviation). These range from familiar clinical skills, used relatively regularly but high risk to the patient (such as rapid sequence intubation and advanced airway) to totally new elements which are high risk for me and my team as well as the patient (such as winch and flight currency), and the assessment is undertaken in a form of simulation, be it manikin or winch sim trainer based.

Educational theory tells us that one of the best ways to embed knowledge is through spaced repetition; regularly revisiting learning at gradually increasing intervals. When these skills are first introduced they are practised very regularly and intensively (during induction and helicopter ground school), and although there is an regular due date for currency, it can be renewed more regularly at the discretion of the practitioner. How do we maintain clinical currency?

smaccFORCEThis is done in conjunction with our paramedic colleagues for clinical skills and aircrewmen (with or without paramedics) for our flight and winch skills, the team members with whom we are likely to be using these skills. Because we are training with the team we will be working alongside for real, we are able to maintain that community of practice and flattened hierarchy, and draw on a wealth of experience and wisdom from which all can benefit. Because we practise the clinical skills regularly, there is a familiarity that can allow overall processes to be broken down into micro skills, enabling deliberate practice where required.

What about in hospital then? Let’s think beyond the tick boxes – what are the high risk things your team does? In Manchester, we found that regular multi-disciplinary team simulation of simple cardiac arrest scenarios improved team communication and rapidly exposed competence or lack thereof.

What about life, limb and sight-saving procedures? Can your team perform these when needed? Does every member of your team understand why they are being performed and what is involved?

Culture

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Thirdly, I want to touch briefly on culture; specifically on the culture of governance within prehospital services.

Think about your last clinical governance or audit day. What was included? Was it more than just dry lectures and powerpoint slide after powerpoint slide of wrist slapping?

The service I work for approaches governance through daily “coffee and cases” medical team reviews of recent cases and fortnightly clinical governance days to which all staff are invited and practitioners from outside our branch of service may attend. Content includes clinical audit, case review, simulation and direct teaching in the form of interactive lectures and journal club. These sessions acknowledge that the deliberate practice we undertake is not just practical – there is a cognitive, decision-making component too.

As well as learning from cases where things didn’t go so well, it’s important to celebrate, recognise and learn from successes too. 8

And this is an embodiment of Kolb’s reflective cycle– we can extrapolate specific experiences into broader lessons – what is key in this situation is to have a culture which permits learning from both positive and negative experiences without fear of reprisal or personal criticism. This culture needs to be role-modeled by senior clinicians and lived out by all involved for maximum effect.

Lewin’s change model describes a process of breaking down existing practice in order to reshape it into something different and the CGD is a perfect environment for doing that at an organisational level.

How does your department handle experiential learning? Do you have a clinical governance day? How often? How open and non-judgemental are you? Do you celebrate the awesome and amazing as well as the M&M?

So what about me?

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Image courtesy of Andreas Kruger

Of course, as a medical education enthusiast, I want to reflect on my own experiences. With all this fantastic education have I become a prehospital specialist? No, of course not, but I’ve faced my fears, of flying and of the dreaded HUET and filled a book with the things I’ve learned from the cases I’ve worked on. Without a doubt, this job is making me a better clinician.

So my final questions to you are these:

Has prehospital practice made you a better clinician?

If so, how will you use what you’ve learned to teach, motivate and inspire others, in order to bring the outdoor classroom indoors?

Nat

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