Strategies to manage Complex Resuscitation: Chris Hicks
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Resuscitation is complicated, but the solutions don't have to be. Chris Hicks brings you four psychological strategies that will help you manage complex resuscitations. It is a fascinating time to be a resuscitationist with ROBOA, ECMO and EPR. Chris explains that as we learn more about critical illness, we learn more about the complexities of resuscitation. Therefore, we need ways to manage and constrain complexity and to simplify and organise problems that will see us through. Chris’ lessons are founded on a case. A 22-year-old female is brought into the Emergency Department. She was an unrestrained driver in a motor vehicle accident. She is agitated, has multiple facial smash injuries, burns to her torso and neck, a right sided flail segment, and a mechanically unstable pelvis. Also, when you ultrasound her abdomen, you realise she is well into the third trimester of a pregnancy. Chris discusses four strategies to cope in a complex situation. The first is grounded in habits. Habits have a lot to do with whether or not we succeed at a given enterprise. They can help break down complex problems into simpler parts. Once a habit has been practiced and rehearsed, it becomes harder to not execute the habit than it is to execute it. Next Chris advises to foster emergent organisation in the team. This is self-organisation in teams whereby individual simplicity can create organised complexity. During periods of high task loads it makes sense to create smaller teams to create divisional lines. This allows semi-autonomous teams to function independently towards a specific goal. Thereafter, try to factor down complex problems. Take a problem as you see it and lead it in a direction you’d like to see it. By simplifying a problem into a few sentences, you assert that you understand it, and you can then begin to manage it. Finally, Chris talks about limiting variability. This is in order to constrain chaos. Eliminate variables and thereby eliminate unnecessary steps. This can sometimes mean cutting down team size – Chris conjects most teams are too big! Join Chris as he takes you through four strategies to manage complexity in a complex resuscitation. Lean on habit. Foster emergence. Factor down the problem and limit the variables.
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Strategies to manage Complex Resuscitation: Chris Hicks
- 5. Habit
- 8. Emergence
- 13. Factor Down
- 17. Limit variables
- 18. A B
- 21. Lean on Habit Factor Down Limit Variables Foster Emergence
- 22. @humanfactOrz
Hinweis der Redaktion
- -we live in complex times ... -the more we learn about resuscitation the more we realize how complex critical illness actually is; and with that comes the need to manage and constrain complexity, because when things get really complicated, its ;precisely our ability to simplify and organize problems that will invariably see us through -This is Pompei by German-born abstract impressionist painter Hans Hoffmann – as striking as it is simple -“The ability to simplify means to eliminate the unnecessary so the necessary can speak”
- -complex systems aren’t just more of something, they behave differently; changing scale of a problem means changing rules -googol – not complex -compare to this, a nine digit prime number: more complex even though its much smaller, because its surface complexity can’t be broken down any further -Kolmogorov complexity = number of bits of data it takes to describe an object, scenario, thing w/o losing information
- -consider your next patient -22F unbelted partial ejection, facial smash and burns, L flail chest, distended abdomen, presumed AP compression fracture, L/E open # and partial L L/E amputation; oh yes and a gravid uterus to boot -can practically hear people’s sphincters slamming shut
- -Our work for the next 15 mins: What do an abstract impressionist painting, a googol and a trauma patient have in common? -Interesting convergence in domains of art, science, philosophy, mathematics, design emphasizing the importance of simplicity that I don’t think is an accident --“Simple can be harder than complex: you have to work hard to get your thinking clear.” –Steve Jobs -That’s what we’re talking about here: KISS = more than platitudes, you need a strategy – a pick-list of organizational and behavioural hacks, help you get with the science of simplicity
- -”first we make our habits, then our habits make us” –Charles Nobel -habits both good and bad have a lot to do with whether we succeed at something or we don’t -repetition and habit: take otherwise difficult tasks and make them easy by breaking them down into small, more manageable steps -when sufficiently practiced, it becomes easier to enact a habit than to not
- -habit vs goals: overstate the endpoint without considering the steps between -“I want to save this trauma patient’s life” vs. “each time I manage a trauma patient in shock I approach it thusly” -discussed in performance psychology for elite athletes, deliberate emphasis on process rather than outcomes; having a standard approach to X constrains complexity and and puts you at a better point on the performance-arousal curve
- -situation awareness is relative: you have to know where you stand in order to be able to detect and manage variance -having a standard approach or habit to a given situation amplifies your/your team’s ability to detect outliers, atypical features so common in complex scenarios -example: leading team through standard trauma assessment – no major deviations because of a baby, and burns (at least not initially)
- -Once you’ve done that you can shift focus to fostering emergent organization within your team -A process of self-organization by which individual simplicity can generate organized complexity -simple agents interacting according to simple rules can organize into more sophisticated entities to solve complex problems -believed to underpin everything from how neurons assemble to create intelligent neural networks to how large businesses organize their workforce to respond to complex market demands -Striking example: Starlings flock together: a traditional algorithm would lose accuracy over time – couldn’t possibly account for all the intrinsic and extrinsic variables of the flock
- -viewing the problem according to emergence theory, you could instead try to predict behaviour of the group based only on the interaction of individual members and let the complexity emerge from there -three simple rules: fly in the same direction as everyone in your cone of vision, don’t collide with other birds, stay close for protection (separation, alignment, cohesion)
- -dramatic complexity emerges from very simplistic components that far exceeds the sophistication of individual elements of the group
- -you can foster emergent problem solving based on how you choose to set up your team -here’s a typical functional team structure, groups of individuals working in a unit, ortho in the time-out chair (wouldn’t stop fucking with the pelvis)
- -during periods of high coordination overhead it is often helpful to set up your team along more divisional lines -sub teams – semi-autonomous groups that exist for a set period of time and are focused on specific tasks -eg. airway team: agree on a plan, approach, back-up, then do the same for chest tube, pelvic binder -the role of the team leader is to foster emergent order among team members without trying to over-engineer it – to create the conditions by which team members can work together to achieve manageable, tangible objectives
- -see the situation not just as it is, but how you would like it to be, and be able to convey that to your team
- -Nate’s breakfast example -Our brains are hard wired to respond to complex systems in one of two ways: -Dive deep and focus on areas that are comfortable or familiar to us – can lead to fixation, blind spots -Try and take the whole problem in at once, which we can’t do – so we start to make up rules, assumptions -you mind works the same was as Nate’s during periods of stress and high task load
- -tension between simplifying and micro-managing a situation -good leaders can factor down not all the way but a level or two from surface complexity to make the situation more approachable -this will explain the vast majority of variables in a given problem and allow you to isolate and focus on one or two specific areas of concern
- -ability to bottom line a problem, as is done with NASA space crews -also seen in leadership, politics, anything where people need to be influenced – nail a concept down succinctly is key -bottom lining this patient: “we have an airway problem and a circulation problem” – then start to chunk up and assign tasks based on that, or how you would like them to be (great metal model tool)
- -or, containing chaos by limiting the number of paths a particular event is permitted to take – this is minimalist resuscitation -this comes back to Kolmogorov complexity: what is the minimum amount of data required to describe a situation without losing information
- -can you actually get from point A to point B in a resuscitation, process – good example of which is carrying out a complex procedure -my advice: pick 3-4 processes/procedures that you view as complex, and run through the steps start to finish – eliminate those process/logistic barriers -then make it your habit to do so on a consistent basis (sara gray and the bougie cric example) -then: limit number of steps (from 5 to 3) by way of object or process design; shrink teams wherever possible to minimum required, eliminate redundant tissue
- -limiting variables also means to better understand what your team members do: too much time on admin, away from their teams: blind spots when your team has to come together to solve a complex problem -Regular departmental cross training exercises using ISS – eliminate the variable of what other people know and do -Not only that, but address complexity by promoting team member engagement; This is the basis by which inter-professionalism works – not just taking orders but engaged in the problem solving process
- -point on environmentalism, global warming – is truly an overwhelming problem when taken in all at once -this is not to say you shouldn’t have lofty goals in life, but rather to recognize how breaking down complex goals into more manageable bits will help you get there
- -back to the case -- we reverted to a standard process of assessment before rapidly formulating a shared MM and plan of attack -fostered emergence by way of mini-teams on airway, chest tube and hemodynamics/baby who worked semi-autonomously during different periods of the resus -once initial resuscitation was underway, ostensibly this became a difficult airway case – the rest, for at least a while, could go to hell -limit variables by shrinking the team, and thank goodness we took the time to develop a simplified bougie cric ariway kit that took all of four steps to complete
- -You can either reign complexity in once its already happening, or commit to making the up front investment to manage it before things come unfurled -it’s not the whole story – would love to hear your simplicity hacks as well, so holler at me on the twitter machine -let’s help each other out in this complex world we’re all living in -dream big, but plan simple