Learning To Speak Resuscitese

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In the resus room, clarity of communication between team members is critical to patient safety and effective resuscitation. We are used to following standardised clinical algorithms for cardiac arrests and many other emergency presentations, but there is no standardisation of vocabulary or communication style. Communication failures are a major source of error in resuscitation, suggesting this is an area in which we need to improve.

Defining your lexicon

A contrast with the aviation industry was drawn by neonatologist Dr Nicole Yamada, who points out that pilots and air traffic controllers use an effective, concise, standardised set of words and phrases that are universally understood, for example ‘stand by’, ‘unable’, ‘read back’, and ‘cancel'(1).  She proposed adapting a similar resuscitation-specific lexicon modelled after aviation communication which ‘would aid in streamlining communication during time-pressured clinical situations when seconds count and errors can kill.‘(2)

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Dr Yamada tested this approach in a small study of simulated neonatal resuscitation. Standardised communication techniques were associated with a trend toward decreased error rate and faster initiation of critical interventions.(3)

Avoiding the fluff

In the absence of standardised approaches to communication, humans in the resus room often choose language which indirectly acknowledges social hierarchies. For ad hoc teams, phrases may be chosen which are least likely to offend people with whom we’re unfamiliar, or may be deferential in cases of real or presumed authority and expertise gradients. The consequence of this is the use of ‘mitigating language‘. Examples might be:

“Any chance you could pop a line in?”

“Would someone mind letting me know if they can feel a pulse?”

“Do you want to have a think about setting up for intubation?”

“How about we get some bag-mask ventilation happening at some point?”

“If you could have a look at his abdomen that would be awesome”

These commands (imperatives) phrased obliquely as questions or suggestions are know as ‘whimperatives‘ and are found throughout resus room dialogue, when the team leader does not wish to convey the assumption of a power relationship over her colleagues. These whimperatives are an example of ‘mitigating speech’, which refers to language that ‘de-emphasises’ or ‘sugarcoats’ the command.

In the words of Peter Brindley:

‘The danger of mitigating language illustrates why, during medical crises, we should replace comments such as “perhaps, we need a surgeon” or “we should think about intubating” with “get me a surgeon” and “intubate the patient now.”’(4)

Conclusion

There’s nothing wrong with being polite and respectful, and mitigating language may be helpful in the team building phase. However the more critical the situation, the more an authorative/directive leadership style that clearly delegates critical tasks  is required(5). Standardised terminology (with closed loop communication) is likely to enhance clarity of the message and accelerate the sharing of a team mental model. Avoiding whimperatives and excessive mitigating phrases may further prevent ambiguity and imprecision, reducing the time to critical interventions.

These components of the content of resus room communication – unequivocal, standardised, and direct – should go hand in hand with the delivery of the words. Effective delivery requires optimal delivery speed and ‘command presence’. These factors will be discussed in a future post.

I’d be interested to hear what standard phrases or words you think should be in the resus-room lexicon.

 

1. Yamada NK, Halamek LP. Communication during resuscitation: Time for a change? Resuscitation. 2014 Dec;85(12):e191–2.

2. Yamada NK, Halamek LP. On the Need for Precise, Concise Communication during Resuscitation: A Proposed Solution. The Journal of Pediatrics. 2015 Jan;166(1):184–7.

3. Yamada NK, Fuerch JH, Halamek LP. Impact of Standardized Communication Techniques on Errors during Simulated Neonatal Resuscitation. Am J Perinatol. 2016 Mar;33(4):385–92.

4. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. Journal of Critical Care. 2011 Apr;26(2):155–9.

5. Bristowe KK, Siassakos DD, Hambly HH, Angouri JJ, Yelland AA, Draycott TJT, et al. Teamwork for clinical emergencies: interprofessional focus group analysis and triangulation with simulation. Qual Health Res. 2012 Sep 30;22(10):1383–94.

Reflections on an ass-kicking

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Last weekend I got my butt handed to me and I’m feeling really good about it. I entered my first Brazilian Jiu Jitsu competition, and was beaten unequivocally, having had to submit to avoid having my arm broken after about three minutes into the fight. So what’s to be so cheerful about? Essentially, the whole endeavour was an experiment, and the experiment was a success. I learned a heap about learning, and about myself. Lessons that can be applied to learning resuscitation medicine, or learning anything.

The 10000 hours fallacy: not all hours are created equal

I’ve been doing Brazilian Jiu Jitsu (BJJ) for about a year, and am not very good at it. I started it because my (then) five year old son started it, and I thought it would be nice if we could share an interest in something healthful and useful for self protection. For most of that year I made 1-2 sessions a week, usually rushing to class after an emergency department or retrieval medicine shift and not really having my ‘head in the game’. Turning up. Just like it’s possible to turn up to work, get through your shift, and go home and forget about it.

I noticed something interesting about the people who started around the same time as me. Those who were entering competitions – as inexperienced and ill-prepared as they were in the beginning – progressed much faster than me. They would break down techniques and work on specific movements or positions they knew they needed to improve because of their competition experience, and they’d ask targeted questions of the coaches, aimed at maximising feedback for them to work on. It dawned on me that I was witnessing something I’d described in a lecture on Cutting Edge Resuscitation performance at the Royal College of Emergency Medicine Conference last year:

What seems to be apparent is that although many hours of practice are important, pure exposure or experience alone does not predict those who will master their subject. We may have all encountered colleagues who have many years under their belt who lack that spark you’d expect of a cutting edge expert. So merely turning up to work every day doesn’t make you better, it just makes you older. You reach a certain level where you can manage the majority of cases comfortably, after which more exposure to the same experience fails to improve performance expertise.

What differentiates the cutting edge performers from the majority in all these domains (studied areas such as chess or sports or music) appears to be the amount of deliberate practice, or effortful practice, in which individuals engage in tasks with the explicit goal of improving a particular aspect of performance, and continue to practice and modify their performance based on feedback, which can come from a coach or mentor or the results of the performance itself.

“Competence does not equal excellence” – Weingart

 

With this realisation, I decided to enter a competition I was extremely unlikely to win. I knew that committing (publicly) to a deadline would force me to improve my game, and I turned up more, studied the notes I’d made, and started asking more questions. In the space of a few weeks I felt that my BJJ was progressing faster than before.

The powerful combined forces of deadlines and public commitment

There’s nothing like a deadline or a high stakes test or exam to focus the mind. I’ve done several postgraduate fellowships and diplomas by examination, some of which were optional, and I’m sure each one raised my knowledge and clinical ‘game’ more than any other educational intervention I can think of.

The reality of the competition day approaching forced me to tackle my training, fitness, diet and timetable in a way I otherwise would not have found the motivation for. I had a strange moment when I took off my teeshirt in the changing rooms prior to the match and caught sight of my reflection in the mirror. I barely recognised how different my physique was compared with months earlier. Previously, I’d exercised for its own sake and not made much progress losing the middle aged paunch. But the public commitment to a BJJ fight, in a certain weight category, instilled the drive to exercise and monitor my diet. Commitment to this deadline physically restructured me!

Stress exposure training WORKS!

I’ll be 49 this year. The only people available in my weight category to fight me were aged 36-40. Age can make a big difference. Injuries are not uncommon and a significant one could put me out of training or out of work. My wife and son and friends were going to watch me, and I didn’t want to let them down or put on a pathetic performance. All my buddies who had competed before warned me of the overwhelming nervousness that can disorientate you and cloud your concentration. There were plenty of potential negative outcomes to focus on, but I ignored them all. I knew the simple formula. Breathe. Talk. See.

This basic mantra, assisted by the mnemonic ‘Beat The Stress’ (BTS) developed by Michael Lauria, is something we teach and apply in the training department of Sydney HEMS. Breathe means control and pay attention to your breathing, allowing you to reduce sympathetic hyperactivation and be ‘in the moment’. Talk means positive self-talk: a silent internal monologue that reminds yourself of all the preparation you’ve done and the potential positive outcomes of the task about to be performed. See means visualise: run through in your mind a successful performance, imagining yourself overcoming any anticipated obstacles – a practice which prepares your mind and body for effective task execution.

Less than a week ago I was running workshops on human factors for Sydney University Masters of Medicine (Critical Care) students, and covered how we submit our new HEMS clinicians to stress exposure training in order for them to practice Lauria’s BTS approach. Throughout these workshops I couldn’t wait for the opportunity to test what I teach.

On the day, my only interpretation of my adrenal surge was excitement. Even in the ‘holding pen’ after weigh-in where you wait with other competitors to have your bout, there was no anxiety, no fear. I couldn’t wait to get on the mat. The whole thing was an exhilarating buzz, and even when the can of whoopass was being unloaded on me I felt cognitively ‘available’: aware of my surroundings (and predicament!) and able to control my breathing while I self-talked my way through my limited and ever dwindling options.

Conclusion

It might be slightly unusual to be singing from the rooftops about a defeat, but the educational principles I’m re-learning are worth re-sharing. I took myself out of a comfort zone, and made a public commitment to be tested. This focused my learning and made me practice in a different way and more proactively seek feedback. I no longer was ‘turning up’, I was training towards a goal. This renewed sense of ownership of my training transformed my level of engagement in the learning process, instilling an enthusiasm and craving to understand and test principles rather than rote learn techniques.  I had an opportunity to test ‘Beat The Stress’ in a non-clinical setting and this mindware tool proved itself yet again. And despite the uninspiring outcome on the day, I was back sparring the following evening, with an even greater hunger for specific answers from the coaches, and with senior students remarking ‘you’ve got better’.

Further reading and listening:

Sydney HEMS training (Reid)

Achieving mastery (Weingart)

Cutting edge performance in resuscitation (Reid)

Stress exposure training (Lauria)

Martial arts and the mind of the resuscitationist – do it like you f***ing mean it’.

Sydney Jiu Jitsu Academy