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Educating Resuscitators:Seeking “Conscious Competence”
Peter Brindley MD FRCPC FRCP-EdinClinical Intensivist…and proud of it
Other Stuff: Professor, CCM, UofA
Adjunct Professor, EthicsAdjunct Professor, Anesthesia
Division ofCritical Care Medicine
“Sophisticated intensive care often becomes unnecessarily
expensive terminal care when the
pre-ICU system fails”
Peter Safar 1974
Resuscitation circa 1970s
ICU Competencies:ResuscitationDiagnosisDisease ManagementProceduresPerioperative-CareComfort and recoveryEnd of Life CarePaediatricsTransportSafetyProfessionalism
How do we learn/teach
DON’T KNOW & aren’t aware
Not always good learners
DON’T KNOWbut aware
Often GOOD LEARNERS
KNOW, but not always why
Not alwaysgood teachers
KNOW, but takes effort
Often GOOD TEACHERS
Noel Burch/Gordon Training Inst
“Every system produces results that it is designed to…”
“Accidental Curriculum”: what do we teach?
“Accidental Competence”: how do we teach?
“Accidental Curriculum”Aron D. 2002
Safety data not widely shared
We don’t know if what we teach works
Rely upon random presentation
Train, educate…or simulateAron D. Qual Saf Health Care 2002
Brindley Crit Care 2010
What competence is most important in patient safety?
A.Factual Knowledge?
B.Procedural dexterity?
C.Communication/team skills?
Errors in Medicine
Human factors > 80%
Communication/teamwork >70%
Gaba DM, et al. Crisis Management in Anesthesiology. 1994St Pierre et al. Crisis Management in Acute Care Settings.2008Sutcliffe KM. Acad Emerg Med 2004Khan FA et al. Anesthesia 2001Brindley Critical Care 2011; J Crit Care 2011Etc, Etc, Etc
“Meant is not said
Said is not heard
Heard is not understood
Understood is not done”
“Close the loop”
“Verbal dexterity”
“Avoid mitigating language”
“5 levels of advocacy”
“Repeat back method”
Rall and Gaba 2007Brindley and Reynolds J Crit Care 2011
SBAR
“Never let an aircraft take you somewhere your brain didn’t already go”
“fly ahead of the plane”Ron Coley, US Marines
Failure to plan= plan to fail• Shared mental model• Give your team advanced permission • Airway: verbalize a plan A,B,C
www.skygod.com/quotesberkeley.edu/news/berkeleyan/1998/0225/coley.html
Errors of planning, not execution
• Superior to additional practical training
• Supplements (doesn’t replace) training
• Early evidence for CRM imagery
Mental Training in Surgical Education: Randomized Controlled Trial. Immenroth et al 2007; 245 (3) 385-391. N=98Chris Hicks, UofT (with permission)
Where does med education start?
2 seasons41 intubation attempts
Zero correctly positioned
Brindley and Needham Resuscitation 2009
Flex lower c-spine
Extend OA joint
Ears in front of sternum
Airway Positioning
Sniffing pos’n 1936 Magill
Brindley et al. BJA 2010
Win with the chin:An alternative to the sniffing position for teaching
airway intubation
Brindley. Resuscitation 2008
Anatomic…………………………37% correctSniff ……………………………….15% correctWin with Chin…………………43% correctControl…………………………… 20% correct
”Win with Chin” significantly better than sniff
“Sniff” worse than no instructions !!
Brindley et al. BJA 2010
Any Evidence?
Least recorded BUT most specific predictor…of cardiac arrest and unplanned ICU
Pulse-ox not a replacementEducation priority!? Conscious competence
MJA 2009
S Finfer- with permission
Preparing for complexity
• “A physician is a healthcare worker authorized to work outside of guidelines”
Prof Julian Bion, personal comm
Teaching complexity?SIMPLE COMPLICATED COMPLEX
EXAMPLE Bake Cake Fly to moon Raise child
PREDICTABILITY High Medium Low
PERSONNEL Solo Team Team/Community
EDUCATION Learn & Practice
Break into steps
?
STRATEGIES Task trainer Simulation Experience
Zimmermann and GloubermannA Gawande. Checklist Manifesto
Simulation 2.0 : five insightsInefficient for t’ching v-efficient way to learn
More than training/education patient safety lab
Experiential, reflective deliberate
“Social justice imperative” “hygiene imperative?”
Address human factors personality;teams;culture
Brindley P.G. Crit Care 2010; De Gara C, Brindley P.G C.J.Surg 2012St Pierre 2008; A Ziv (personal corresp)
Experience/time
Performance
factsskills
behaviours
Simulation speeds acquisition
Basics of Competence
Simulation decreases decay
Fight; Flight…or Freeze
Automatic:Cognitively embedded Near Immediate
Simple DecisionsMore than one possible response availableChoosing takes few seconds
Complex decisions No appropriate response embedded, Response has to be created : many seconds
Inability to make decisionsNothing embeddedNo temporary schema can be created
Leach J, Aviat Space Environ Med 2004
SIM
Competent
Incompetent
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