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© 2006 Cisco Systems, Inc. All rights reserved. Presentation_I D 1 Cisco Public Managing Difficult Scenes Rakesh Bharania Catherine Nelson Rick Santina Another day, another response to Cisco!

Cisco ERT - Managing Difficult Scenes

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Emergency scene management course for the Cisco ERT

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Page 1: Cisco ERT - Managing Difficult Scenes

© 2006 Cisco Systems, Inc. All rights reserved.Presentation_ID 1Cisco Public

Managing DifficultScenes

Rakesh Bharania

Catherine Nelson

Rick Santina

Another day, another response to Cisco!

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© 2006 Cisco Systems, Inc. All rights reserved. Cisco PublicPresentation_ID 2

Agenda

What’s this all about?

Skills for when it’s going wrong.

– Scene assessment & safety

– Tips for providing better patient care

– Managing a tough crowd (or a tough patient!)

– Effective communication and authority

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Most emergency responses at Cisco are relatively routine and follow patterns that we become readily attuned to.

But this class isn’t about those calls at all…

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 3

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Real Stories!

The scenarios we describe are all based on real calls at Cisco. Some of the details have been changed to emphasize specific points.

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Scenario 1:Scene Assessment

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Cisco ERT is called to a cubicle for a man with a “cut on arm.” Upon arrival, you find a man bleeding from a lengthwise, deep laceration to his wrists.

He was working in the datacenter when the injury occurred and then moved back to his cubicle. There is a large amount of blood on the walls, floors and furniture around him.

Co-workers indicate that the man sliced himself with a box-cutter while doing work in the datacenter…

What is your scene size-up? What concerns do you have?

What is your next action?

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 6

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Cisco ERT is called to a cubicle for a man with a “cut on arm.” Upon arrival, you find a man bleeding from a lengthwise, deep laceration to his wrists.

He was working in the datacenter when the injury occurred and then moved back to his cubicle. There is a large amount of blood on the walls, floors and furniture around him.

Co-workers indicate that the man sliced himself with a box-cutter while doing work in the datacenter…

Did you catch the hazards?

How does this affect scene safety? Where is the weapon? Is this a violent situation?

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 7

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Emphasis on Scene Safety

Scene safety is something we emphasize but many times at Cisco, responders will enter a scene and never give it a thought.

Your only goal should be: I and my team-mates go homeat night, unharmed.

What hazards should you be aware of when on scene? Assess for hazards on every call. Assuming safety is a good way to get hurt. Work with the buddy system – remain in contact with one another

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Keep the goo off of you (redux)

You already know to glove up when working on a patient. Is there a contaminated scene too? Use eye and face protection. Do: Reach into your bags now, and pull out your eye and face

protection. Have you ever used them before? Prepare: “I will use my protective eyewear when…” “I will

use my gloves when…”

SJFD requires eye protection when patient is vomiting, etc. A good protocol to follow.

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Violent scenes – they happen

Workplace violence (fights, shooters, etc.)

Violent patients (diabetic, epileptic, behavioral, others?)

Remember that emergencies are dynamic – what was safe ten seconds ago may no longer be safe.

If the situation is known to be violent – stage well away. Wait for word that a scene is secure (you may not be going in anyway)

If a situation becomes violent – get out! (You did leave yourself an out, right?) Once safe, report to the IC to ensure everyone gets out too!

On the radio: “Priority Traffic” urgent situations (not threatening to the team)

“Emergency Traffic” for emergency situations (e.g. threat to yourself, team, etc.)

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Scenes are Dynamic

Incomplete pager / radio information (sometimes just plain wrong)

You may have to switch roles – handoffs.

Doing smooth handoffs.

You may need more resources

Scene conditions will change: crowds, patient moves, additional patients.

Advise IC of developments, let IC make the call.

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Scenario 2:Decision-making and Patient Care

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You get called out to a medical …

You’re called to the childcare center for an unconscious and seizing 18-month old boy who fell from a height and hit his head while playing.

You walk into a chaotic scene in the classroom – there are a dozen toddlers running around and playing, oblivious to the situation.

The adults around the child are in near hysterics, shaking the child and trying to rouse him.

You stand there for a moment: you’re not trained for pediatric emergencies, but you’re worried about further harm.

You freeze.

What concerns do you have?

What is your next action?

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 13

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You get called out to a medical …

You’re called to the childcare center for an unconscious and seizing 18-month old boy who fell from a height and hit his head while playing.

You walk into a chaotic scene in the classroom – there are a dozen toddlers running around and playing, oblivious to the situation.

The adults around the child are in near hysterics, shaking the child and trying to rouse him.

You stand there for a moment: you’re not trained for pediatric emergencies, but you’re worried about further harm.

You freeze.

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 14

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Avoiding “analysis paralysis”

Before you get on scene: pre-brief (“block”) your actions as you’re headed to the call. You can do this if you respond with others or by yourself.

If the situation is so weird it’s throwing you off, remember OODA The OODA loop was designed for fighter pilots in the middle of high-

speed combat. 1. Observe2. Orient3. Decide4. Act5. Go back to #1

When confused: act in the best interest of the patient consistent with your training.

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Traps in your patient assessment…

“Anchoring” – the tendency for a first responder to lock onto a patient’s initial presentation and failing to adjust that impression in light of information gathered later. (aka tunnel vision)

I was so focused on maintaining CSPINE that I didn’t notice the patient started to have real problems breathing…

“Confirmation bias” – the tendency to look for signs/symptoms that match your predispositions. We get called on this frequent flyer all the time. It’s always a seizure. But this time I ignored the signs that pointed to a diabetic emergency…

“Search satisfying” - the tendency to call off a search or examination once something is found.

At a datacenter rack fall, I found a compound fracture in the patient’s right forearm. Splinting that, I failed to detect the patient’s compromised pelvis…

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Customer Service

Introduce yourself to your patient by name.

Assure the patient that you’re there to help.

When getting a handoff from other ERT or bystanders, look them in the eye, and thank them for their report or help.

Make the patient as comfortable as possible.

Don’t patient-jump or criticize other ERT actions in front of patient or others. Save it for the debrief.

Don’t cop an attitude with anyone.

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Building a quality team

Debrief and mentor each other

– Ask questions about anything you didn’t understand or were curious about.

– Debrief honestly but constructively.

– Be open to critiques (even seasoned ERT can learn new things)

– Mentor each other: let people get patient time (consistent with pt care, of course) or be IC.

– Everyone prepares to play all roles.

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Scenario 3:Communications

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You arrive at the “cut on arm” incident 10 minutes into the event…

The IC gives no guidance but sends you to the patient scene. You find the patient shirt off, cuffed, face down, blood all over, Surrounded by police, fire, a lot of ERT and S&S.

ERT and fire and are trying to treat patient but its proving difficult due to the police action.

A growing crowd of hovering co-workers, is getting more and more agitated about the treatment the police are giving the patient.

There are large amounts of blood in the main hallway and lab.

What is your scene size-up? What concerns do you have?

What is your next action? Why are the police here?

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 20

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Communication and Authority

The ERT is a volunteer team, you have limited authority. But most people will respect someone who acts like they’re competent.

When dealing with a tense situation, body language and tone of voice are critical.

Approach in an assured manner without being hostile. Always treat them with respect.

Keep your hands at your sides, do not cross arms, or stand in a legs apart stance.

Turn your radio down. Keep your voice calm, look them in the eye and talk directly to

them. Do not order them. Acting in an authoritative manner tends to escalate matters

and give them something to “fight” which if they are agitated, is exactly what they want.

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Communication and Authority

Listen to what they have to say. When people feel they are heard and have choices, they calm down.

Say who you are, what you would like them to do and why. Most people when they understand what’s going on, will cooperate.

If need be deputize them to help, then they become part of the solution and will usually stop any hostile action.

If they argue use the “I understand (what ever their issue is) … AND we have an emergency can you please (offer an alternate solution) …”

If you feel they don’t listen to you, be persistent but polite with your request.

If you absolutely have to – giving a direct order will often get people to respond, but will lose you good will and cause resentment. Use this sparingly and only in critical need.

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Scenario 4:Scene Control

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You get called out to a medical …

A pregnant woman is brought to the lobby by co-workers. She is in pain, getting hysterical, and has blood on her jeans from a vaginal bleed. There are a total of three ERT – of which, only one of you is female – and a couple of security mobiles.

As you start to wonder when fire is going to show up (since time is slowing down!), she becomes increasingly upset.

People are starting to return from lunch… what do you do?

What is your scene size-up? What concerns do you have?

What is your next action?

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 24

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Scene Control

Once you’ve established patient care…

Scene control is critical to the to the smooth operation and safety of any event.

Ask co-workers and even bosses or relations to leave the area.

Get the patient privacy and the emergency crew easy access and space to work.

If need be redirect people away from the lobby, hallways, to different doors into the building etc.

Control the elevators for fire and AMR

If not enough resources, deputize bystanders to redirect traffic.

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Scenario 5:Complex Crowd Control

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You get called out to a fire alarm …

It’s lunch time people and cars are everywhere

You are standing in a six-way intersection. The parking lot is gridlocked with cars in every direction, people are trying to both get in, and get out of the lot. It’s becoming chaotic.

Its raining, people are standing all over the parking lot, asking if it’s a drill, trying to get past you to get in the building, and stepping in front of cars.

The ERT is short staffed, there is only you for traffic, then you hear the fire trucks coming.

What concerns do you have?

How do you handle the crowd?

What about scene safety?

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 27

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You get called out to a fire alarm …

It’s lunch time people and cars are everywhere

You are standing in a six-way intersection. The parking lot is gridlocked with cars in every direction, people are trying to both get in, and get out of the lot. It’s becoming chaotic.

Its raining, people are standing all over the parking lot, asking if it’s a drill, trying to get past you to get in the building, and stepping in front of cars.

The ERT is short staffed, there is only you for traffic, then you hear the fire trucks coming.

What concerns do you have?

How do you handle the crowd?

What about scene safety?

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 28

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Complex crowd control and multitasking Your top priority is your own safety.

What can replace your body in the danger zone? Utilize other resources (cones, tape, security vehicles) to simplify the area you are trying to manage.

Priority two – employee safety. Use your whistle and your command voice to keep people out of the way of traffic. Get them to move to a “safe place”.

Priority three – property protection. The fire department needs a clear path to the fire. Try to keep cars and people out of the way; don’t compromise your other priorities. People tend to get out of the way when the engine is rolling toward them.

Priority four – communicate when possible – use the bullhorn to communicate to large numbers at a distance.

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Review: Difficult Scenes

What is the first thing you do when entering a scene? How would you handle a hostile patient? How would you handle a situation where the patient might be

at risk from the current care takers? How do you handle a crowd of “concerned” co-workers trying

to “help” your patient or just watch? How do you handle a crowd of impatient and irritated workers

who have no interest in listening to you. What mannerisms or communication tactics might work best?

What are your roles. How do you deal with law enforcement and fire?

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Thank you for volunteering.

© 2006 Cisco Systems, Inc. All rights reserved. Cisco ConfidentialPresentation_ID 31

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Questions?

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