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PrehospitalAdvancedNon-TechnicalSkills
ManagingtheEnvironment
Safety(irst.Controlspace,light,heat,noise,hostility/distraction
Identifyandcontrolworkspace Controlyourenvironment,don'tletitcontrolyou
ManagingSelf
Physicalreadiness:
I'MSAFEchecklist-illnessmedsstressalcohol/drugsfatigueeating/elimination
Fullstomach,emptybladder.Hungry,Angry,LateorTired?=HALT
Cognitivereadinessandresilience:
Stressaffectsmemory,attention,judgement
Stressminimisationstrategies:
Teambrief(enroute)
Visualisation(between,before,enroute),andaccess'performancestate'
Mindfulness(be'inthemoment',attentiontobreathing)
Metacognition(thinkingabout/awarenessofyourthoughtprocesses)
Reducecognitiveload:SOPs,simulation,controlenvironment,delegate,checklists
Simulationwithstressexposureandperturbationimprovesadaptabilitytonovelconditions
Post-missiondebrief
Stayintherightperformancezone-‘combatbreathing’canlowerheartrateandrestorefocusand(inemotorcontrol
Cognitiveandperceptuallimitationsanderrors
No-onecantrulymulti-taskwell
Perception/mapofworldconstructedbybrainfromlimiteddatasomuchofitisbestguess/madeup
Muchofmemoryisaconfabulatednarrative
Stressmakestheseevenlessreliable-veryeasytomissthings/befooled
Visualandattentionalresolutionlimitedtotinypartofvisual(ield-(ixationonataskleadstolossofsituationalawareness
Behaviouriscontext-speci(ic:youcan’tassumeyouwillperform'normally'inunusualcircumstances
Bystandereffect=contagiousinaction;betheonetospeakup/act.Useyour‘discontinuitydetector’(thisdoesn’tAitwithwhatIthinkisrightandIamgoingtoact)
ManagingtheTeam
Managingalargeresusteamandmakingthingshappen
Establishassertiveleadership–verbalandphysical
Manageexpectationsandbiases-rememberpeoplemightonlyseetheuniformandassumenon-specialistambulanceof(icershavearrived:‘IamDoctorReid,[consultant]anaesthetist/emergencyphysician/intensivist.I’mthecriticalcarephysicianleadingtheretrievaltoday.
Taskappropriately;dothingsonlyyoucando
Remove/reducedistractions-giveannoyingpeopleajob
Setgoalsandsharementalmodel:de(inethe'missiontrajectory'&temporality(whatandwhen)
Resuscitationbyvoice:commentaryapproach(cfblackboxessilentminutesbeforecrash)
CrossMonitoring-watchingeachother'sback
Closedloopcommunication:Doctor:“Give20mgKetamineiv,that's2mls”Paramedic:“20mgthat's2mlsofketamineiv”Doctor:“That’scorrect”
Preventingandmanagingcon(lict
Communicationstyles: Aggressive:Whatthehellhappened
Submissive:I’msorrytobotheryou
Cooperative:Icoulduseyourhelp
Assertive:ThisiswhatIthink
Overlyaggressiveorsubmissiveapproachescanchangefocusofinteractionfrompatientcaretopower.
'Howaboutwe','Couldyouplease','I’dlikeusto'=‘mitigatinglanguage’–goodforteambuildingbutnotforimmediatecrisismanagement
Dealingwithauthoritygradients:Advocacy–5stepapproach
1.Attentiongrabber–excusemeDrGina
2.StateConcern(basedonFACTStheycan’tdisagreewith)–hehasasigni(icantheadinjuryandhashadnminutesofrelativehaemodynamicstability.Keepitaboutthepatient(advocacy)
3.Statetheproblemasyouseeit–wecan’tmanageallofhisclinicalneedsinthishospital
4.Stateasolution–let’sworktogethertogethimtothetraumacentreinthenext30minutes
5.Obtainagreement–wouldthatbeokaywithyouDrGina?
Manyorganisationshavedevelopedgradedassertivenesstools:
QANTAS:RAISE:Relayinformation;Askiftheyareaware,seekclari(ication;Indicateconcern;OfferaSolution;EmergencyLanguage(“Youmustactnow”orasimplecommandsuchas“GoAround”)
Military:PACE:Probingforabetterunderstanding;AlertingCaptainoftheanomalies;Challengingsuitabilityofpresentstrategy;EmergencyWarningofcriticalandimmediatedangers.
OnecriticalassertionstrategypresentlyusedinthehealthcaresettingistheCUSprogram(fromTeamSTEPPS).CUSstandsfor“I’mconcerned;I’muncomfortable;thisisunsafe.”Followedby“STOP-Youmustlisten!”
TrafKiclights:
PersuasionandInKluence
Beniceandbeliked
Beauthoritative(butnotaggressive)
Findcommon(tribal)ground:–wevs.they
Statefactsanddon'tgetpersonal
Usethegroup-powerof'socialproof'
Askforhelp–morelikelytogetmorefavours(commitment&consistency)
Hypnosistools:pacing,leading,presupposition
Alighttouchontheupperarmcanincreasepersuasionandtheperceivedstatusofthetoucher(careful!).
Compare“He’sbleedingandyouneedtotakehimtotheatre”
with: “Hisbloodpressureisnow85systolicandtheFASTispositive.Heneedstogettotheatre tocontrolthehaemorrhage’
Whatabout: “We’reworriedhisbloodpressureisnow85systolicandtheFASTispositive.Howfastcan youhelpusgethimtotheatresoyoucansavehislife?”
Whatin(luence/persuasionprinciplesareemployedinthatsentence?
TacticalLanguage
Acquiresomerehearsedphrasestohelpyougetthejobdonewhenyouencounteroranticipateresistanceorteamdiscoordination.Embedsomeofthepersuasionandhypnosistoolsabove.