M0: Introduction and Basic Principles
‘The State of Play:
The current situation or circumstances.’
— Idioms, The Free Dictionary. *
‘At the finish, you must reconcile yourself to failure. It’s not perfect. You have to make your peace with that. How? Well, you sit at your board, you lay out your tools, and you start again.’
— Leonard (The Outfit) *
M0: INTRODUCTION & BASIC PRINCIPLES | M1: ANESTHESIOLOGY | M2: INTENSIVE CARE | M3: THORAX | M4: PEDIATRICS | M5: NEURO | M6: PHYSIOLOGY | M7: PHARMACOLOGY | M8: ULTRASOUND
0 — Introduction & Checklist For Managing Crisis
1 — Principle One — Good Intentions are not Enough
2 — Principle Two — Know Your Team & Your Resources
3 — Principle Three — Assume Nothing & Cover the Fundamentals
4 — References
( 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 )
Introduction & Checklist For Managing Crisis ^
Welcome to Change The State of Play and my introductory course on anesthesiology. The next seven modules cover the basics of anesthesiology and intensive care but first; what I consider to be the most important principles to implement in your daily work.
Changing the state of play means changing the current situation. From chaos and imminent death to, in the best case scenario, order and a stabilised patient. For this to happen you need have immaculate knowledge of physiology, anatomy, pharmacology, and pathology. You need to be familiar with and know your resources and your team well.
I can’t stress the importance of clear communication, good checklists, situational awareness, and seamless teamwork — you know, the cornerstones of Crew/Cockpit Resource Management (CRM). It’s for good reason why we practice in teams and do regular simulations. Doctors, similar to pilots, need to routinely practice and improve on their CRM skills, or planes crash and people die.
Checklist for managing and preventing crisis [SFAI/ESA 2019/2020]
- Get to know your (work) environment and change it when needed!
- Anticipate and plan! Tell your plan to your coworkers!
- Have a low threshold when it comes to asking for help!
- Make it clear who is the team leader and clarify personal roles across the board!
- Distribute the workload across the team!
- Use all available resources!
- Effective communication!
- Use all available information!
- Avoid flailing!
- Check and double check!
- Use aiding tools!
- Re-evaluate often!
- Cooperate as good as you can!
- Re-evaluate and change your prioritisation’s!
Principle 1 — Good Intentions are not Enough ^
Being a physician comes with responsibility. You need to know what you are doing, and perhaps more importantly what you don’t know (see also: The Dunner-Kruger effect). Having good intentions are not enough, you need to have the knowledge and the set of skills needed for your particular profession, and know/understand your limitations/shortcomings, or people’s lives will be at risk.
Those years in medical school and then internship and residency are a testament to the knowledge and skill-requirements of the profession. But they are not enough, the field of medicine is constantly changing and part of the job is to stay up to date with significant changes and new treatment/procedure guidelines.
Good intentions are not nearly enough, you need to be well informed and, more importantly, you need to evolve with the field of medicine and the current best practices.
Principle 2 — Know Your Team and Your Resources ^
The better knowledge you have of your environment and your coworkers, the more ready you are to handle any crisis turning up. Life in an emergency hospital is a lot about showing up and handling acute situations. The people in your team and the tools at your disposal are your greatest asset.
Get to know your team, everyone plays an invaluable role — from the nurses aids to the radiologists to the admins. Whether in the ER, OR, or in the ICU do check in’s with the team. Establish roles and use clear (loop) communication. At the end of each case, each shift, and/or critical moment, do a check out if time/circumstance allows for it. Focus on the good but also on what can be improved for the next time and/or crisis. Give praise extensively for the meticulous care and diligence everyone puts in and encourage initiative, doubts, and questions. Make sure everyone feels safe to be heard and show respect and appreciation for individual efforts taken to make sure the patient gets the best possible care.
Principle 3 — Assume Nothing & Cover the Fundamentals ^
Someone told me once,
The ABCs of anesthesia are: Assume nothing, Believe no one, Check for yourself.
We have to, of course, trust our coworkers to a certain extent or work as part of a team in hospitals would be impossible and/or dreadful. But there is also value in double checking the important stuff. Humans make mistakes, and every re-evaluation adds value for the patients as a safe-guard against mistakes going unnoticed.
The greatest daily failings of the healthcare system in hospitals are not rare diagnosis or “zebras” as we call them, but the plain and routine pathologies and procedures (the plain old ‘horses’) that are either missed or done improperly. The largest number of healthcare failings are due to simple things like: poor communication failures, improper medicine ordinations, poor hygiene routines, missed lab-tests and ECGs, etc etc.
The basics and fundamentals of healthcare work are the most important to get right and to be diligent about. The basics might not be the most difficult part nor the most exciting part — but they are, perhaps for those very same reasons, the most undervalued and overlooked. Learn the basics, then repeat the basics, often and consistently. Return to the fundamentals, again and again. Learn to love the basics, doing them well is the prerequisite for mastery.
Having said that, you will still fail at times, even at the basics. And even when you don’t fail, there will always be something you could have done better at the end of the day. Make your peace with the fact that life on-call in the hospital will never be perfect, each crisis is different, all we can hope is to get as close to perfect management as possible. At the end of each shift return to your team / notes / checklists / journal / board — lay out what you could and can improve and start again…
C H A N G E T H E S T A T E O F P L A Y.
- Kruger & Dunning. ‘Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments.’ 1999.
- ‘We Are All Confident Idiots’ — Essay by David Dunning on the Dunning-Kruger Effect (see also: original paper above). 2017
- ‘Thank Goodness’ — Essay by Daniel C. Dennett on why good intentions are not enough in the medical world. 2011.
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