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Crisis m anagement final

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DavidHakim83

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Crisis m anagement final

  1. 1. Crisis Management David Hakim, M.D. FRCPC Arnaud Robitaille, M.D. FRCPC
  2. 2. Sorry….
  3. 3. Where it all started
  4. 4. GP3R
  5. 5. GP3R
  6. 6. My Hospital
  7. 7. Conflict of interest
  8. 8. Objectives • Familiarise ourselves with crisis management principles • Find how to improve our response under stress
  9. 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. 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. 11. Solution • If we can understand how our brain works, we can understand how to improve our response
  12. 12. Solution • Cognitive psychology • Situational awareness
  13. 13. Cognitive psychology Intuition Reason
  14. 14. System 1 Which alley to choose?
  15. 15. System 2 • 61 425 • 62 655 273 X 225 = ??
  16. 16. Cognitive psychology Intuition Reason
  17. 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
  18. 18. Situational awareness
  19. 19. Situational awareness • We think that we have a good perception of our environment, that’s a mistake, it’s a big challenge
  20. 20. Situational awareness • In a crisis situation we need to find, choose, integrate, interpret and organise information Raw Data Useful, organised
  21. 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. 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. 23. Example • Poor response to 100% O2, fluids and even vasopressors • Desaturation • Elevated peak pressure • Hypotension • Tachycardia • Tear and blood in suit
  24. 24. Example • Poor response to 100% O2, fluids and even vasopressors • Tension pneumothorax, need to be decompressed
  25. 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. 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. 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. 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. 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. 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. 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. 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. 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
  34. 34. Intuitive Jugement Clinical Situation Scripts
  35. 35. Clinical Situation Scripts Intuitive Jugement
  36. 36. Clinical Situation Scripts Diagnostic accurate and fast = good results, positive reinforcement Intuitive Jugement
  37. 37. Clinical Situation Scripts Intuitive Jugement
  38. 38. Situation clinique Scripts Bad script selection= Inaccurate mental image= Inaccurate perception. Intuitive Jugement
  39. 39. Fixation Scripts
  40. 40. Scripts Fixation Situation clinique
  41. 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. 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. 43. Optimise team work • Designate a leader • Good leadership and good followership • Good communication
  44. 44. Optimise team work It is crucial to clearly and rapidly designate a leader
  45. 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. 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. 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. 48. Practice, practice, practice • The classic way to prepare for crisis management does not work on the good cognitive system
  49. 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. 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. 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. 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

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