They say emergency medicine and critical care are no picnic, but I’ve been trying to change that. There’s something about sitting down on a blanket and sharing protected time for conversation that makes for good team building and effective communication. If you have snacks, it’s even better.
In the emergency department or intensive care unit one sometimes has to be opportunistic regarding finding time for teaching, debriefing a resuscitation case, or even eating. We end up doing these things (if at all) on the fly, in a rushed manner, and often standing up. Do we really have to? All you need for a picnic is a blanket, a floor, and some people. Hospitals have these. If you don’t want to be seen, pop outside or use a bed space with a curtain round it.
Here’s an example of an impromptu picnic. It was late in the evening, early 2013. After two busy resus cases, my senior registrar and I debrief picnic-style, with potato chips from a vending machine and a nice pot of tea. We’re still in the ED and available to our team, but anyone can clearly see we’re in the ‘picnic zone’ and so we’re left alone for ten minutes to gather our thoughts and identify any learning points. The ED is usually a factory of interruption, but no-one wants to interrupt a picnic.
Here’s resident teaching. We don’t have time to leave the ED, but there’s always time for a picnic, during which we cover a surprising number of critical care topics. People won’t fall asleep while picnicking.
And here’s a picnic with the intensive care trainees outside the unit. This is actually lunch, but why shouldn’t lunch be a picnic once in a while?
We’re encouraged to practice mindfulness and take mental time out as a way to prevent or manage stress in the critical care environment. I think this is enhanced with an accompanying brief physical time out too. One person sitting on a blanket on the floor might be a weirdo. Get two or more people, and you have a picnic. Everyone loves a picnic.
‘Do what you said you were going to do – the high performance culture of excellence under pressure’ is the title of a talk by General John Jansen, organised by my friend A/Prof Brian Burns on behalf of Sydney University.
It will be held on 20 December at 18.00 hrs at the Royal Prince Alfred Hospital in Sydney.
Free Registration available here, and refreshments are provided.
My whole career has been about finding ways to optimise resuscitation. Many others also have the bug. The ‘resuscitationist movement’ is sweeping across Europe, with Katrin Hruska and Femke Geijsel about to run amazing courses for emergency teams in Sweden and The Netherlands. I have the honour of joining Clare Richmond in helping them do that. But first Critical Care in the Emergency Department is going to be run in London one more time.
This course contains the stuff I wish someone had told me as a registrar. A synthesis of my learning points in intensive care, prehospital & retrieval medicine, paediatric critical care, and being a front line ED doc for 20 years.
I’ve been running the course for over a decade, including in London, Birmingham, Basingstoke, Dublin, Stockholm, Sydney and Maribor. Each time I try to improve it, and try to squeeze one or two more learning points in. It’s a tough day – just me and fifty or so critical care cases to talk about. But no-one goes to sleep – guaranteed! Everyone has to work – to talk, think, and interact.
It is of course primarily a clinical course, focusing on optimal clinical practice. But consistent feedback from participants is that they get far more from it: a reassurance that they’re not crazy wanting to do more for their patients, and a way forward for remaining inspired and motivated to make changes to their practice and to their departments.
If you’re able to make it to London next Friday 26th August treat yourself to a day of training you’ll never forget. There are no planned future dates for this course in the UK so get it while you still can!
I’ve always had strong feelings about education. I was an uninspired and underachieving medical student, exasperated at the fact that the preclinical course at my medical school consisted of lengthy lectures about detailed aspects of basic sciences like histology and embryology. To make it worse, the teaching was delivered by basic science PhD students who were required to teach medical students as part of their contract. They taught because they had to, not because they were good at it. In other words, the best way to summarise how I was initially taught to be a doctor is this: my medical training consisted of being taught stuff I didn’t need to know, by people who weren’t doctors, and who didn’t know how to teach.
This frustrated me enormously. It wasn’t until I hit the wards as a senior medical student and then junior doctor that I would occasionally run into enthusiastic and supportive clinicians who were keen to share what they knew. They seemed to be few and far between, but the crumbs they dropped were enough to leave a trail that led me to be determined to become a doctor who could similarly inspire and motivate others to love learning.
Throughout my training I made a consistent observation: a small amount of good education was extremely motivating. The converse was also true – being denied access to education was extremely demotivating. In one department, teaching was continually cancelled due to patient load. When questioned on this, the clinical director stated “teaching is a privilege, not a right”. This influenced me profoundly, because I immediately adopted that phrase as a personal motto, except that I flipped the order of “right” and “privilege”.
A few events have converged this week to remind me of the power of good education. The first, and most important, was when my friend Rob Rogers, a renowned emergency medicine educator who has run courses on how to teach all over the world, tweeted a picture of an interesting ECG.
Rob and his team have inspired so many people with their brilliant education. Faced with a life-threatening ST-elevation MI, Rob chose to share his ECG with his Twitter followers. Later he shared details of his angiogram pre- and post-revascularisation. Now THAT is commitment to education!
The second event this week is that we are running our Sydney HEMS induction course in prehospital & retrieval medicine. This is about as full on as medical education can get, with hours of simulation, testing, and stress exposure. I am constantly amazed at the dedication and hard work of my colleagues who make up the course faculty, and the willingness of the participants to go the extra mile to improve their performance. We have the honour of inviting medics from certain branches of the Australian military to attend the course, and one such armed forces ‘graduate’ of our course recently contacted me:
He attached a document outlining a situation he faced which took my breath away. I’m not yet allowed to share it, but the bravery he showed was awe-inspiring. To think that he credits some of his preparation to the training we gave is truly humbling. It is also a reminder of the enormous responsibility of educators.
We can provide both negative and positive inspiration through our choices in what we say and how we say them, and in the teaching we deliver. As learners those educational experiences shape us and stay with us forever, influencing the choices we make and how we choose to pass on the teaching.
The humbling feedback from my military friend along with Rob’s ongoing desire to educate in the face of life-threatening illness serve to remind us of the power of education, and the responsibility we educators have to share, to inspire, and to provide the highest quality teaching.
Something Rob already seems to be working on, less than a week post-myocardial infarction …
@hayleybsa 8am on the 14th…working on the schedule now…Course is going to be FANTASTIC!
I love education. As a trainee, I was lucky to be guided by a handful of excellent mentors along the path. The truth is however, in many places I worked inspiration and good education were hard to find.
I am driven by the desire to make my trainees and colleagues better than me. As a critical care physician, I can only save so many lives in one career. But as an educator I have an opportunity to influence patient care in regions of spacetime to which I will never have personal access.
A massive investment has gone into my medical education. My parents worked their butts off to allow me to study. State funded university education in England got me my medical degree. Taxpayers’ money paid my salary throughout my training. Most importantly, thousands of patients put their trust in me as I did my best to learn medicine by treating them, sometimes getting it right, often getting it less than optimal. I owe all of them. I owe it to them, and to myself, to make it all count as much as possible.
If I can ignite a spark in a trainee’s mind that inspires them to improve, or share a memorable clinical tip that gets recalled and applied at a critical point in a resuscitation months or years from now, then all that investment, all that sacrifice, is so much more worth it.
Here’s a list of the principles I try to apply, especially when running courses. Underlying all of this is the goal to provide the kind of training I would have loved to have received myself.
Cliff’s Clinical Teaching Tips
Keep it case-based
This allows the nurse, the specialist, and intern to be in the same classroom. When we’re considering patients, everyone can learn something that is relevant to their professional perspective and experience.
Respect the learner
Allow everyone to question the teaching and express their opinion. Never humiliate anyone. The less threatened people feel, the more exploratory their questions will be, and the better they are able to make sense of the information discussed.
Have regular breaks, with food, water, and caffeine
If people have travelled to learn, they need to be protected from fatigue, dehydration, neuroglycopaenia and caffeine withdrawal. If they know you care about these things, they know you care about an effective learning environment, and will be more engaged.
How to make it memorable
Make it fun
Learning is great fun. We should have a good time together. If you’re bored, you won’t learn effectively. Funny or unusual stuff is more memorable, too.
Critical care is emotive. During resuscitation we have powerful interactions with ourselves and with our colleagues, sometimes negatively. Learners who are experienced clinicians have all felt pain or frustration in the resuscitation environment. Addressing these issues, by focusing on what could be done better, from a self, team, environment, or systems point of view frames the clinical teaching in more realistic and more applicable context. Sharing my own feelings about cases I’ve managed shows the learners how similar we all are inside, and I’ll be better able to convince them that they are just as capable of applying what is taught as I am. We can advise learners more effectively how to think and behave if we immerse the teaching in the reality of human experience.
Keep it simple
A quotation often misattributed to Einstein is “If you can’t explain it simply, you don’t understand it well enough”. Resuscitation and critical care concepts, certainly as applied to the initial resus room evaluation and therapies, can all be explained in uncomplicated ways. It behooves any resuscitation educator to adhere to this.
Have a framework that you continually refer back to
Knowing where to ‘store’ new information and how it relates to existing knowledge or other concepts being taught is important for understanding and retention. A classic example of such a framework is the ABCDE trauma assessment, but many more can be created. It also facilitates communication of ideas though mindmaps or note taking via sketchnotes.
This relates to connecting emotionally, as recommended above, but there is more to it. Humans have communicated information and ideas through storytelling since the dawn of civilisation. We are hardwired so that our attention is captured by stories.
Mnemonic tools like acronyms are helpful for information that needs to be rapidly accessed, like the one I made for possible causes of a raised lactate when you’re looking at a blood gas from a patient in the resus room with a lactate of 12 mmol/l.
I’ve been in the privileged position of being able to apply these principles in courses I’ve run in various countries for over a decade. In 2016 I get to do it again in the Netherlands, Sweden, and England. I’m one very lucky educator!
This talk was the opening plenary given at smacc Chicago. The title they gave me was ‘Advice To A Young Resuscitationist. It’s Up To Us To Save The World‘ but I ditched the last half because, as I point out later in the talk, I don’t think it is up to us to save the whole World. Some AV muppetry at the conference centre prevented the smacc team from being able to include the slides, so I’ll post those too at some point. You can hear the talk as a podcast at the ICN or on iTunes
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.
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’.
We’re in the business of sudden death. As prehospital, emergency, acute medicine and intensive care clinicians, facing the reality of the tragic loss of a living person, loved by their friends and family, is our day job. This makes me think we shouldn’t really have any reason to be ‘shocked’ or ‘surprised’. But we have every right to be sad.
The news came in the same week as the tragic Flight for Life Helicopter Crash in Colorado, bringing us another unwelcome reminder of the dangers of prehospital work. My HEMS colleagues and I are always mindful of the possibility that every time we get in the helicopter it could be our last, and I’ve no doubt John appreciated this reality when responding on his motorcycle.
Two weeks ago John and I gave two of the opening talks at the SMACC conference in Chicago. My talk went first – entitled ‘Advice to a Young Resuscitationist’. I attempted to list a number of tips that could help a resuscitationist become more effective at saving lives while surviving and thriving in our often traumatic milieu. The talk will be uploaded soon, and I’ve listed the pieces of advice below. What strikes me now like a slap across the face with a large wet fish is the realisation that John exemplified every one of these characteristics and habits:
1. Carve your own path that takes you on a richer path than that worn by trainees in a single specialty
John was an anaesthetist, an intensivist, and prehospital doctor.
2. Never waste an opportunity to learn from other clinicians – leave your ego at the door. See any feedback as an opportunity to learn and to improve, no matter how painful it is to receive.
Despite being among the best in his field, John would on occasion discuss challenging cases and ask if we could think of anything else that should have been done (our answer being, without exception, “no”).
3. Have the confidence and self-belief to perform actions you are competent to perform when needed, to avoid the tragedy of acts of omission.
John’s amazing talk on “crack the chest – get crucified” (when no-one else would) shows how he embraced this mindset: do what needs to be done – with honourable intentions – and manage the consequences later.
4. You can’t save every one, but you can make each case count. When a case goes wrong you need to change something – yourself, your colleagues or the system.
John was a super-agent of change wherever he operated. One beautiful example is how in one hospital the thoracotomy tray ended up being named after him!
5. Caring is so critical to what we do, and is one of the most important things to patients and their families.
As Greg Henry taught me (quoting Theodore Roosevelt) : ‘Nobody cares how much you know until they know how much you care’
John was gentle, kind, and humble. So many of his tributes remark on his compassion and dedication to patients.
7. Strive for balance in your life and your work. Consider part time working or mixing your critical care with a non-clinical or non-critical care interest.
John was revered and loved within the world of motorcycle racing, a passion he managed to combine with his flair for critical care.
8. Train your brain to be aware of and to utilise strategies that protect it against cognitive traps and avoidable performance limitations under stress – learn the hacks for your MINDWARE.
Many of us now introduce stressors into our simulation training to help us learn to deal with the adrenal load of a difficult resuscitation. But I doubt many of us can hope to achieve the intense focus and concentration under pressure that is required of motorcycle racers. John sent me a link to this video of racer Michael Dunlop a few weeks ago with the comment ‘How about this for a scare!’
9. Maintain perspective. It’s not all about you or your resus room.The most effective resuscitationists save lives when they’re not there. They work on the systems – the processes, the training, the governance, the audit, the research.
John was a brilliant educator and systems thinker. The care given at the roadside, in the ED, the ICU and the operating room at many sites is better because of the teaching he gave and the approaches he developed.
10. Understand that everything you say and do in a resuscitation casts memorable impressions in trainees’ minds like the tossing of pebbles into a pond, whose ripples reach out and out to affect so many future lives and deaths in other resuscitation rooms.
You can imagine the obstacles and personalities John faced when trying to improve care in the environments in which he worked. But through it all he remained a gentleman. Always constructive, always collaborative, always supportive. I’ve never heard him say a bad word about any named individual or criticise another specialty. He truly embodied the non-tribal spirit of SMACC, which sets an example for us all to aspire to, and will influence future resuscitation room behaviour in far-reaching locations.
11. Behave as you would want to be remembered, and be mindful of the extent of the ripples in the pond. But don’t let that put you off throwing the pebbles – embrace the challenge of the highs and lows and above all enjoy the ride, for it is awesome.
In just 35 years of life John saved the lives of many and changed the lives of many more. He knew how to throw pebbles and wasn’t afraid to point out the lack of emperor’s clothes around many traditional aspects of medical practice. And that smile seen in all the pictures of him shows there’s no doubt John enjoyed the ride, and it was awesome. Thanks to his wit, intelligence, teaching, charm, and resuscitation brilliance, he helped us enjoy it all the more too.
I spent a lot of time preparing my talk ‘Advice to a Young Resuscitationist’. It’s clear to me now that I needn’t have bothered. Sharing the stage with John, I could have saved everyone’s time by simply saying: ‘Try to be like THIS guy’.
I am extremely privileged to know him, to have learned from him, and to have shared some moments from his days at smaccUS.
We will mourn, we will remember, and we will honour him by being the best resuscitationists we can.
Day three is Air Ambulance and pre-hospital day and the great and the good are here en mass.
The heavy weights are coming out to make their points…..
Unarguably the best lecture of the day was delivered by our very own Cliff Reid on prehospital training. Using Sydney HEMS induction training he highlighted the challenges posed to prehospital services training doctors and paramedics rotating through the service.
Turning a good inhospital doctor into a great prehospital one in the space of an induction program requires focus. Knowledge is therefore not the focus of training, performance is. Often doctors already possess the clinical skills and knowledge and it is the application of these pre existing skills in challenging environments when cognitively overloaded that is the key.
The Sydney HEMS program provides the mindware and communication skills the practitioner needs to do this and drills these skills in simulated environments. He uses perturbation, so like the Bruce protocol exercise test the simulations just get harder until you are at the very limits of your bandwidth. Debriefing of course is important but the recommended protracted debrief is often impractical and unnecessary so simulations designed with cognitive traps are used to highlight learning points and are drilled until the message is received. In this way tress exposure enhances cognitive resilience. And importantly they use cross training, so the doctors and the paramedics undergo the same program so each member of the team understands the challenges faced by the other.
Does this sound like fun? For the shrinking violets out there it could be seen as threatening. But for the adrenaline junkies…….hell yeah!
It’s truly a training ethos that I buy into and I’d love to be able to achieve that standard of training in my own service.
How would you transfer a psychotic patient requiring specialist intervention that can only be received after aeromedical transfer? Stefan Mazur of MedSTAR, the retrieval service in South Australia shared their experience with ketamine to facilitate the safe transfer of these patients with no reports of adverse effects on the mental state of the patient, as first described by Minh Le Cong and colleagues. Is there no end to the usefulness of this drug? No wonder we’re experiencing a supply issue in the UK!
And finally, the ultimate reflective practice should include the post mortem of our critically sick patients. The approach the forensic pathologist takes is similar to a clinician (with the time pressure removed). They read the scene and use this information to predict injuries (sound familiar?). Post mortem CT scanning with recon provides yet another layer of information. We are missing a trick if we don’t seek this feedback to correlate with our clinical findings. Even better, rare practical skills are often routinely performed as part of the post mortem – we should be making use of this opportunity to train.