Your group must reach a decision as to which four persons can enter the life raft. You have approximately 30 minutes to reach this decision before the aircraft sinks.The following are the details of the nine survivors.1 'Ace' Browning. Ace was the pilot at the time of the crash and it was his expertise which landed the aircraft in one piece, enabling it to float. 'Ace' received his pilot training and nickname when he was in the Airforce. He is the son of an Air Vice-Marshall and a decorated Gulf veteran. He is a keen golfer and collects theatre memorabilia. Recently, there has been some concern amongst his colleagues that he is showing signs of a drinking problem. He is one of a team of volunteer pilots who carry out mercy missions which drop food and medical aid in places of crises.2 Geoff McGraw. Geoff was returning from a medical conference where he gave a paper on "Re-building Facial Features Following Accidents". He is a recent divorcee with four grown up children. At 57 he owns a plastic surgery clinic in California from which he has made a considerable fortune. Geoff has established a charitable programme which helps children with facial injuries. His hobbies include collecting vintage cars, deep sea fishing.The Butler family - James, Patience and Prudence3 James Butler is a 40 year old church minister. He has been a missionary in Papua New Guinea for the past 15 years. He is keen to take up the challenge of a new post in Haiti, but has not discussed the move with his wife, Patience, as he is aware that she is anxious to return to the UK and start a career. He is also torn by the wish to spend more time with his two older children. James' hobbies are bridge and fishing.4 Patience Butler (35) did a lot of voluntary work whilst in Papua New Guinea. She established a youth club which developed skills such as orienteering and homecrafts in young people. For many years Patience has wanted to start a career; she has the manuscript of a first book which she intends to take to a publisher. Her book explores issues relating to helping indigenous peoples and their way of life survive the 21st century. She has three children.5 Prudence Butler. Prudence Butler, an epileptic, was travelling from Papua New Guinea to London with her parents at the time of the accident. She is a very intelligent 10 year old girl and shows great talent at music and languages. She has two siblings, a fourteen year old brother and a 12 year old sister who are both at boarding school in the UK. Prudence did not want to take time out of school for this trip but her father felt that it was important that she visit her brother and sister.6 Donald Heap. Donald Heap is a 45 year old married man with two children. He is the Conservative member for Happiburgh and currently resides on the back bench following a brief, but very public period as Junior Minister in the Department for Defence. Donald resigned from this position because of a scandal involving insider dealing. Donald is a self-made man, having made his fortune in sports clothing. He is an Olympic medallist in track events and used his world-wide reputation as a sportsman in marketing his goods. His hobbies include sailing, squash and growing hothouse orchids.7 Sam Comfort. Sam is a 29 year old nurse and a member of Greenpeace. He abandoned plans to marry three years ago and took up a post as Nursing Officer at an Antarctic research station where he carried out work on hypothermia. He got on very well with the rest of the team at the research station and would like to renew his contract and return there. Sam is a very gifted musician, he plays the violin and enjoys swimming and badminton.8 Professor MuChado. Professor Chado has been Professor of Microbiology at the University of Barkington for the past 10 years. He has developed an antibody to the HIV virus that has proved successful in combating illness in experimental animals. He is 60 years old and a bachelor. He was physically disabled when he was 30 in a riding accident and has since then been confined to a wheelchair. His hobbies include water colour painting9 Philippa Lowes-Harrington. Philippa Lowes-Harrington is a Performance Director in the energy industry. She is a 50 year old married woman with no children. Philippa spent 12 years in the army and retired at the age of 30 at the rank of Captain. Her hobbies include skiing and collecting objet d'art. She has been involved in negotiations where the Victoria and Albert Museum acquired a number of valuable pieces of British art from Japan and the United State. Currently she is the Chair of a working group which is considering how art may be used to improve inner-city environments. Philippa has recently been diagnosed as HIV positive.
Tasks always change. This is just a sample list, must be adaptable and flexible. Constant re-evaluation of allocation of tasks. When a situation changes the entire process must be recalculated and reallocated. Sometimes, everyone must drop everything at direction of supervisor and focus on one or two things. Then must prioritize. What things would get tossed out the window if you have a cardiac arrest, etc? When people come and go, must re evaluate.
CRM for EMS workshop
Crew Resource Management December 2010 EMT-Basic Continuing Medical Education Justin Feldstein, NREMT-B , AC for Training
Outline• Identify common management and leadership problems in EMS• Introduce the concept of CRM and how it applies to EMeRG• Foster critical thinking skills that can be used in emergency and non-emergency situations• Apply concepts
What is Crew Resource Management (CRM)?CRM is a program designed to enhance theeffectiveness of given resources: – Assertiveness – Leadership – Communication – Attitude – Situational Awareness
Foundations of CRM• Developed in 1980 after a string of fatal airline collisions – Tenerife Airport Disaster in 1977: KLM Pilot asks for take-off clearance from tower. KLM Pilot falsely assumes clearance was granted and began take- off without visual of clear runway. The co-pilot was too intimated to speak up and state they were not cleared for take-off. KLM aircraft and Pan am aircraft collide resulting in 583 fatalities.
Hudson River Landing of United 1549Chesley "Sully" Sullenberger"has to go down *as+ the most successful ditching in aviation history.”- NTSB
Bottom LineSimple communication errors ormisunderstandings, based on human error canresult in fatal consequences.– Clear similarities to EMS– Flight crew and EMS crew go from “standby” to “activate” instantly– Crew change all the time, need standardized methods
Bayley, et al (2008)Study of one- versus, two-paramedic treatment scenarios in a simulated cardiac arrestFindings: “...two paramedic crews were more error- prone and did not perform most interventions more rapidly with the exception of intubation. These data do not support the proposition that two paramedic crews provide higher quality cardiac care than paramedic-EMT crews in a simulated ventricular fibrillation arrest.”
Thoughts?• Human factors!• Good Communication and effective leadership are much more important to patient care outcomes that we think – Too many leaders on this one?
Team LeadershipWhat characteristics can be identified in agood leader?• Decision making skills/Conflict Resolution• Authority• MentoringWhat kinds of traits are these?
Followership• Respect authority • Learning attitude• Personal Safety • Ego in check• Crew Safety • Balance• Accepts authority assertiveness/authority• Knows authority limits • Accept orders• Leader success • Demand clear tasks• Good communication • Admit errors skills • Provide feedback • Adapt
Conflict Resolution• Conflict will ALWAYS arise. Unavoidable fact of life.• Key is to resolve conflict quickly before it escalates• Must have legitimate avenue for followers to present issues• Avoid emotional involvement
Conflict Resolution Methods: Crewmembers Questioning Authority• Assertive Statement Method – Used in non-life threatening conditions, “off- scene” – Time is no factor – Diplomatic and respectful approach• “This-is-Stupid” method (TIS) – Reserved for high-risk, short on time scenarios – Last tool in the toolbox – Focuses on actions, not individuals
Crewmembers Questioning Authority: Assertive Statement Method Five Step Process to expressing a difference of Opinion: 1. Opening/attention- say the person’s name 2. State concern/owned emotion- “I’m uncomfortable with…” 3. State the problem as you see it- real or perceived 4. Offer a solution- “I think we should…” 5. Obtain Agreement- “What do you think?”
Practice!Example: Justin, I am nervous aboutdriving right now, I have an exam inan hour that I didn’t study for. How about we do it next shift? Is that cool?
Crewmembers Questioning Authority: “This is Stupid Model” One step process to raise a red flag, making the leader immediately reconsider a situation: 1. Develop a call sign: For example, “Red flag” – Forceful method when tragedy is real – Removes personal issues, focuses on event Automatic Red Flags for supervisors: "I have no idea what you are asking me to do.” "Is this legal?” "I am totally lost.” "Whos in charge?” (CC/Field Sup.)
Practice! Example: Justin! Red Light!Response: Justin realizes he shouldn’tgive nitro to someone without askingif they have taken ED meds in the last 48 hours
Communication• Messages are transmitted and received – Verbal: 7% – Body Language 35% – Vocal Tone 55%• The tone YOU set projects onto your crew – Everyone has bad days, but in EMS bad days can kill people
AuthorityVested by legitimate power – Title and responsibility of EMT, Crew Chief, Field Supervisor, Assistant Coordinator, and Coordinator – EMT-B License – Rights and responsibilities • Both must be balanced and attended to
MentoringFundamental function of leadership position – Goal: Develop and support prospective leaders – Technical competence is essential component: • Demonstrate skills and techniques • Demonstrate professional standards and best practices • Verbalize errors and limitations promptly • Recommend solutions to enhance crew effectiveness • Monitor and assess crew performance • Motivate members, create bonds
Situational Awareness• Evaluating high risk situations• Recognizing changing conditions• Recognizing your limitations• Recognizing equipment limitations
Clues to a Declining Sense of Awareness in EMS• Failure to meet objectives or goals• Use of undocumented procedures• Unknowingly/unapproved deviation from protocol• No one paying attention to radios• Not noticing “scene clues”• Unresolved discrepancies• The “Bad” feeling in your stomach
Activity #1: Human Knot• Stand up, form a circle, shoulder-to-shoulder• place a hand in the middle of the circle and grasp another hand• Put other hand in the middle, grasp a different persons hand• Do NOT let go• Untangle yourselves without letting go of each other’s hands
Activity #1 Debrief• What did I make you do and why?• What communication occurred? – Was it concise• Who became the leader, why?• What challenges did you encounter?• What if I said you couldn’t talk?
“The Hump”If you are close to or about to cross “thehump” you need to make a decision if you areable to stay on shift– Provider wellness is ALWAYS our first priority
Increasing/Maintaining Awareness• Maintain Skill-set: CMEs, on-shift training• Experience: Practice makes perfect• Sleep! – This presents a bit of a problem…we are in college AND EMS• Lifestyle choices – Separate yourselves from EMeRG in your off time• Avoid tunnel vision, snippets of everything going on• Delegate!
Bad Attitudes• “I’m the Supervisor”• “See that X, that’s where you sit”• EMTs are not as good as medics• You haven’t been doing this as long as me• “This is not how we do it in X (Jersey)”
Attitudes and Antidotes• Antiauthority: Don’t tell • Follow the rules, they me! are usually right• Impulsivity: Do • Not so fast, think first something quickly • Taking chances is foolish• Macho • I’m not helpless, I can• Resignation: What’s the make a difference use? • It could happen to me…• Invulnerability: it won’t happen to me!
Activity #2: Plane Crash• Break up into groups of approx 10• A small aircraft crashes in the shark infested waters of the Pacific Ocean. There is damage to the aircraft on impact with the water which causes the electronic systems within to be damaged. The resulting radio failure means that no may-day message can be sent. Of the sixteen passengers on the plane there are nine survivors. The location of the crash is approximately one and a half days from the nearest land. The life raft on one side of the airplane can be used, however there is only room for four persons in it.• Your group must reach a decision as to which four persons can enter the life raft. You have approximately 20 minutes to reach this decision before the aircraft sinks.
Activity #2: Debrief• How did you make your decisions? – Any other motives? (ageism, racism, sexism)• Who took charge? Why?• What roles did group members adopt?• What would you do next time?• Did you identify and use all resources?• Meet goals?• What kinds of behavior helped or hindered the group?• There are no “right” answers (sorry)
J.S.T Ragman, Instructor Trainer, USAFEach of us, regardless of time, experience,qualification, rank or position, can still dostupid things. Be humble.A “fledgling” member of my crew makes thecall. Listen to everyone. Look beyond age,experience, rank and qualifications
Decision Making• Pre-requisite: Good situational awareness• Evaluate Situation: – What needs to be corrected? – What resources do you have? – How can the resources best be used?• Consider consequences of all actions• Make Decision, inform all involved• Evaluate decision, repeat as necessary
D.E.C.I.D.E. Model• Detect the need to make a decision• Evaluate options• Choose option that most appropriately meets goals• Implement• Detect the consequences of implementation• Evaluate the consequences
Example: D.E.C.I.D.E.D: Something doesn’t seem right with this patient, they seem “off”E: Rapid transport or wait for medic (ETA 15 min.)?C: Rapid transport: 2 min transport timeI: Transport priority, make hospital notification, increase index of suspicionD: Pt arrives at hospitalE: Seems like right decision, medic would have taken too long
C.L.E.A.R Model• Used for GROUP decisions only – Clarify the Problem – Look for and share information – Evaluate different solutions – Act on your decision – Review performance
Factors that Affect DM Skills• Physiological factors• Confidence• Feeling of “support”• Cohesive work-team• Personalities• Did I mention sleep?• What else?
Other EMS Specific DM Models• BLS• EMT Assessment Steps• ACLS• Triage – All are algorithms that enable effective decision making and treatment implementation under high stress situations
Task Allocation in EMS• Know your limits – Backup?• Know your crew’s limits• Capitalize on strengths• “seek” out experts• One “bite” at a time
The ScenarioDispatch: 0630 to 19th and E Sts. NW for MVC with two vehicles involved, total of four patients. Scene is safe. GWPD on scene. Windshield survey reveals the following:ATF:• 50 yom• 8 yom (entrapped)• 35 yof• 43 yof (DOA)
Your A GW-1 CrewYou have a crew of four:• Yourself: EMT-II for 2 months, about to be FTO• Driver: EMT for 1 ½ years, solid attendant• Probationer: from NJ, firefighter I, extrication experience, ICS 300• Probationer: 2nd shift on EMeRG, fresh out of Class
Walk me through it…• What needs to be done?• Who does what?• What should YOU be thinking about?• What is the plan? Yourself: EMT-II for 2 months, about toATF: be FTO• 50 yom Driver: EMT for 1 ½ years, solid attendant• 8 yom (entrapped) Probationer: from NJ, firefighter I,• 35 yof extrication experience, ICS 300 Probationer: 2nd shift on EMeRG, fresh• 43 yof (DOA) out of Class
The Scenario: The “Average” CallDispatch: 1230 Corcoran Hall 3rd Floor Chemistry Lab for a seizureYour Crew: – YOU (EMT-II) – Driver: New driver, been in EMS for 6 years – Probationary: Fresh out of class – EMT: Solid BLS skills
Planning• What needs to get done?• Who is the most appropriate person for the job given the goals and resources? Sometimes the best solution still doesn’t accomplish the goal or follow the rules, your JOB is to pick the BEST solution
On-Scene Delegation• No luxury of “pre-planning” – That’s why we TRAIN• Tasks differ on every call, Must be adaptable and flexible• Constant re-evaluation of allocation of tasks• Scene changes = reevaluate
Charlie Foxtrot• Results from failure to delegate, communicate, or technical error – “to err is human”- Alexander Pope• If leader is overwhelmed, crew is overwhelmed• Solution: Prioritize tasks and reallocate tasks, what goes out the window?• Fall back on what YOU know
Assertiveness• One of the most LACKING skills among new providers – Middle ground of clinical behavior – Best parts of aggressiveness without the negative energy – Best parts of introversion without loss-of-self – An individuals opinion can be heard without challenging authority • It clarifies understanding or intent, INCREASING safety
Resources“Crew Resource Management”: John S.Halbrook, BA, EMT-P, Pilot“Crew Resource Management for the FireService” IAFC“One Paramedic or Two?... and the crash ofUnited 173” Chris Carlson, PhD. JEMS.