Educating Resuscitators:Seeking “Conscious Competence”

Peter Brindley MD FRCPC FRCP-EdinClinical Intensivist…and proud of it

Other Stuff: Professor, CCM, UofA

Adjunct Professor, EthicsAdjunct Professor, Anesthesia

Division ofCritical Care Medicine

Resuscitation circa 1780

“Sophisticated intensive care often becomes unnecessarily

expensive terminal care when the

pre-ICU system fails”

Peter Safar 1974

Resuscitation circa 1970s

Impending collapse

Vulnerable patient

Resuscitation circa 2014

ICU Competencies:ResuscitationDiagnosisDisease ManagementProceduresPerioperative-CareComfort and recoveryEnd of Life CarePaediatricsTransportSafetyProfessionalism

How do we learn/teach

DON’T KNOW & aren’t aware

Not always good learners

DON’T KNOWbut aware

Often GOOD LEARNERS

KNOW, but not always why

Not alwaysgood teachers

KNOW, but takes effort

Often GOOD TEACHERS

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 simulateAron 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. 1994St Pierre et al. Crisis Management in Acute Care Settings.2008Sutcliffe KM. Acad Emerg Med 2004Khan FA et al. Anesthesia 2001Brindley Critical Care 2011; J Crit Care 2011Etc, Etc, Etc

“Meant is not said

Said is not heard

Heard is not understood

Understood is not done”

“Close the loop”

“Verbal dexterity”

“Avoid mitigating language”

“5 levels of advocacy”

“Repeat back method”

Rall and Gaba 2007Brindley and Reynolds J Crit Care 2011

SBAR

Skate to where the puck will be

“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

www.skygod.com/quotesberkeley.edu/news/berkeleyan/1998/0225/coley.html

Errors of planning, not execution

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=98Chris Hicks, UofT (with permission)

Motion Capture: NoviceExpert

J Carlson, UPMC

Motion Capture: in Golf

Motion Capture: in Medicine

Dr J Carlson, UPMCWith permission

Where does med education start?

2 seasons41 intubation attempts

Zero correctly positioned

Brindley and Needham Resuscitation 2009

Flex lower c-spine

Extend OA joint

Ears in front of sternum

Airway Positioning

Sniffing pos’n 1936 Magill

Brindley et al. BJA 2010

Really?

Win with the chin:An alternative to the sniffing position for teaching

airway intubation

Brindley. Resuscitation 2008

Anatomic…………………………37% correctSniff ……………………………….15% correctWin with Chin…………………43% correctControl…………………………… 20% correct

”Win with Chin” significantly better than sniff

“Sniff” worse than no instructions !!

Brindley et al. BJA 2010

Any Evidence?

Least recorded BUT most specific predictor…of cardiac arrest and unplanned ICU

Pulse-ox not a replacementEducation priority!? Conscious competence

MJA 2009

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 GloubermannA Gawande. Checklist Manifesto

WHY

HOW

WHAT

WHY

Simulation 1.0

Simulation 2.0 : five insightsInefficient 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 2012St Pierre 2008; A Ziv (personal corresp)

Experience/time

Performance

factsskills

behaviours

Simulation speeds acquisition

Basics of Competence

Simulation decreases decay

Fight; Flight…or Freeze

Automatic:Cognitively embedded Near Immediate

Simple DecisionsMore than one possible response availableChoosing takes few seconds

Complex decisions No appropriate response embedded, Response has to be created : many seconds

Inability to make decisionsNothing embeddedNo temporary schema can be created

Leach J, Aviat Space Environ Med 2004

SIM

Competent

Incompetent

And Finally, let’s re-grow a pair

Yerkes RM, Dodson JD. J Comp Neurol and Psychol. 1908

“All truth passes through three stages:

First, it is ridiculed.Second, it is violently opposed.Third, it is accepted as being self-evident.”

Schopenhauer 1788-1860

Questions, Comments?

peter.brindley@albertahealthservices.caP Brindley Crit Care 2010