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Crisis m anagement final
- 1. Crisis Management David Hakim, M.D. FRCPC Arnaud Robitaille, M.D. FRCPC
- 2. Sorry….
- 3. Where it all started
- 4. GP3R
- 5. GP3R
- 6. My Hospital
- 8. Objectives • Familiarise ourselves with crisis management principles • Find how to improve our response under stress
- 9. The Problem • Under stress, we have a suboptimal response • Classic steps to correct : – Denying the problem – Put the blame on the motivation of the individual or on their quality – Augment our theorical knowledge – Review the procedures or guidelines
- 10. The Problem • In a crisis – It’s hard to think clearly – It’s hard to keep track of what is done and what is to be done – We forget to do things we know we have to do – We get lost in the situation • It’s not about value, or knowledge or motivation
- 11. Solution • If we can understand how our brain works, we can understand how to improve our response
- 12. Solution • Cognitive psychology • Situational awareness
- 14. System 1 Which alley to choose?
- 15. System 2 • 61 425 • 62 655 273 X 225 = ??
- 17. Cognitive psychology • System 2 is rational, slow, well thought, it's the one trained during medical education. – Based on knowledge – Conscious process – Analytic – Slow • System 1 takes over in stressful situations, in fatigue or in unknown situations
- 19. Situational awareness • We think that we have a good perception of our environment, that’s a mistake, it’s a big challenge
- 20. Situational awareness • In a crisis situation we need to find, choose, integrate, interpret and organise information Raw Data Useful, organised
- 21. Example • Desaturation • Elevated peak pressure • Beautiful nurse • Hypotension • Tachycardia • Race control on the radio • Peanut allergy • Tear and blood in suit • Rapid extrication • Media at the door • Desaturation • Elevated peak pressure • Beautiful nurse • Hypotension • Tachycardia • Race control on the radio • Peanut allergy • Tear and blood in suit • Rapid extrication • Media at the door
- 22. Example • Desaturation • Elevated peak pressure • Beautiful nurse • Hypotension • Tachycardia • Race control on the radio • Peanut allergy • Tear and blood in suit • Rapid extrication • Media at the door • Desaturation • Elevated peak pressure • Hypotension • Tachycardia • Tear and blood in suit
- 23. Example • Poor response to 100% O2, fluids and even vasopressors • Desaturation • Elevated peak pressure • Hypotension • Tachycardia • Tear and blood in suit
- 24. Example • Poor response to 100% O2, fluids and even vasopressors • Tension pneumothorax, need to be decompressed
- 25. Example • Desaturation • Elevated peak pressure • Beautiful nurse • Hypotension • Tachycardia • Race control on the radio • Peanut allergy • Tear and blood in suit • Rapid extrication • Media at the door • Tension pneumothorax, need to be decompressed
- 26. Situational awareness • To maintain a good perception of our environment in a crisis is a real challenge • It requires a big cognitive effort • Loss of situational awareness is at the origin of many mistakes in a crisis
- 27. Our difficulties 1. The system 1 is limited facing complex situations but it’s the one that naturally overtakes our decision process during crisis 2. Maintaining a good mental image of the situation (big picture) and a good situational sensitivity is a challenge and a key in crisis management
- 28. How to improve our response under stress 1. Preparation and planning 2. Maintain situational sensitivity and prevent fixation errors 3. Optimise team work 4. Practice, practice, practice
- 29. Careful • A lot of the principles will seem obvious now – This is theory, in a conference – System 2 • They a systematically forgotten – In real life, in a crisis – System 1
- 30. How to improve our response under stress 1. Preparation and planning 2. Maintain situational sensitivity and prevent fixation errors 3. Optimise team work 4. Practice, practice, practice
- 31. Preparation and planning • Know the environment – Take note of the resources before the crisis – Know your coworkers – Know you tools – Know where to get your information • Labs, charts, etc. • Anticipate – Have a plan in advance (everybody’s role) – Permits to diminish the cognitive charge – Help maintain a better situational sensitivity
- 32. How to improve our response under stress 1. Preparation and planning 2. Maintain situational sensitivity and prevent fixation errors 3. Optimise team work 4. Practice, practice, practice
- 33. Maintain situational sensitivity and prevent fixation errors • Fixation errors, definition – Selective perception of the environment – Mental model stays wrong despite of enough evidence to challenge it – Diagnosis or plan stays unchanged despite evidence to challenge it – Loss of situational sensitivity
- 36. Clinical Situation Scripts Diagnostic accurate and fast = good results, positive reinforcement Intuitive Jugement
- 38. Situation clinique Scripts Bad script selection= Inaccurate mental image= Inaccurate perception. Intuitive Jugement
- 39. Fixation Scripts
- 41. • How to maintain our situational sensitivity and avoid fixation errors in a crisis? – Frequently reassess the situation • 10 seconds for 10 minutes • Crisis are dynamic events • Use time out • Is the Dx good, do treatments work, is the problem improving, are there new problems? – Use your attention wisely • Delegate all tasks that compromise your attention or augment your cognitive charge – Team Work • Point 3 Maintain situational sensitivity and prevent fixation errors
- 42. How to improve our response under stress 1. Preparation and planning 2. Maintain situational sensitivity and prevent fixation errors 3. Optimise team work 4. Practice, practice, practice
- 43. Optimise team work • Designate a leader • Good leadership and good followership • Good communication
- 44. Optimise team work It is crucial to clearly and rapidly designate a leader
- 45. Optimise team work • Leader – Person best suited to make the good decisions – Plan action, take decisions, assing tasks – Manage the information (situational sensitivity) – Communicate effectively • Follower – Stay intellectually active – Communicate with the leader • On Dx, give info the leader doesn’t have, etc. – Skills that we can be developed, as leadership
- 46. Optimise team work • In crisis we want to say a lot, but we usually say little • Keep conversation to what’s pertinent to the case (help maintain the leader situational sensitivity) • Three C’s of effective communication – Clear directives – Citing names – Closing the loop
- 47. How to improve our response under stress 1. Preparation and planning 2. Maintain situational sensitivity and prevent fixation errors 3. Optimise team work 4. Practice, practice, practice
- 48. Practice, practice, practice • The classic way to prepare for crisis management does not work on the good cognitive system
- 49. Practice, practice, practice • Simulation – Allows caregivers to be exposed to crisis situations – Helps to develop better judgement in the system 1 – Doesn’t limit on technics and medical aspects – Helps practice leadership and followership – The more real (high-fidelity and in situ) the more useful it is – Debrief after each session • Simulation is a safe place, participants should feel comfortable to ask question in the debriefing without being judged
- 50. Conclusions • In crisis, we are not as good as we think to make complex decisions • We rely mostly on the system 1 to make our decisions • The system 1 has it’s limits • We need to make efforts to maintain our situational awareness • Our medical training prepares us poorly for crisis management
- 51. Conclusion • The principles that we have learned, and regularly use in simulation, offers the hope to better ourselves and our ability to take care of our patients more efficiently and safely.
- 52. Bibliography • Miller’s Anesthesia, 7ème édition (2009) – chapitres 6 et 7 • Crisis Management in Anesthesiology, D. Gaba (1993) – chapitres 1 et 2 • Kahneman D. A perspective on judgment and choice: Mapping bounded rationality, American Psychologist, 58(9): 697-720, 2003. • Kahneman D, Klein G. Conditions for intuitive expertise: A failure to disagree. American Psychologist, 64(6): 515-26, 2009. • Eva, KW. What every teacher needs to know about clinical reasoning. Medical education, 39: 98-106, 2004. • Endsley MR. Theoretical underpinnings of situational awareness: a critical review. In Situational Awareness Analysis and Measurement (2000) • Daniel Kahneman, Thinking, Fast and slow
Notas del editor
- Only for 4 years and I’m an anesthesiologist so I guess I already have 2 strikes
- This is an introduction
- Daniel Kahneman System 1 prefered in crisis situation system 2 in places where we are relaxed like here or in a classroom
- Patern recognition Let's say tonight you come back from the restaurant
- Less intuitive, you have to think, but it cannot end in something else than a 00, 25, 50, or 75 Hard to do in a crisis It's a good example of a task systeme 2 can do but not 1
- System 1 prefered in crisis situation system 2 in places where we are relaxed like here or in a classroom
- You can now see why new doctors on track can seems incompetent they are out of their comfort zone.
- Sometime you may think you know what you are looking for and than miss some very important information
- And sometime you think you found the problem but there is more
- Patient in the clinic had pain so could not self extricate and car was on fire so rapid ex, Initially ok was becoming unstable now intubated, preparing for transfert to Hospital then :
- Patient in the clinic, Initially ok was becoming unstable now intubated, preparing for transfert to Hospital then :
- New informations as you are diagnosing and treating
- no air on right side
- Not sure what this line means: “Permits to diminish the cognitive charge”
- Exemple de l’HSD aigu traumatique dans hors d’un centre de trauma: on oublie souvent de vérifier la colonne cervicale.
- Hallo effect this is what happened to some of you with the gorilla
- Delegating is hard for me, anesthesiologist, i do everything myself, but in crisis, i try to delegate, if i can't, i give the lead to someone else in between
- May be done in advance
- The best leader is not necessarily a Doctor, especially new docs on tracks need to learn that!! Example of info to give to the leader amount of blood on transfusion massive
- Be canadian, be polite!