You can read important facts concerning five more CRM Key Points, including the deft use of resources and information, as well as how to avoid fixtion errors, here:
A Warm-Up Before the Next Five Key Points
If you would like, return to the first part of this series. Then, occupy yourself again with the key points given below and write down briefly what comes to your mind with respect to your own workplace.
- 1. Know the Environment
- 2. Anticipate and Plan
- 3. Call for Help Early
- 4. Excercise Leadership and Followership with Assertiveness
- 5. Distribute the Workload (10-for-10 Concept)
Now, we will go through five more key points step by step. We will also elucidate how they are intertwined with some of the first five and with one another. Partly, they pertain to CRM principles which are already familiar to you. As these are the key points 6-10, the headings will carry these numbers.
6. Mobilise All Available Resources
6.1. What Are Our Resources?
This question might sound mundane, but it is important to occupy oneself beforehand with them in order to use all resources wisely in a complex situation.
Resources in the emergency medical service comprise, for example:
- all teammembers with their knowledge, skills, and attitude
- further teams, for instance, the fire department, and the police
- dispatch (f. ex. information on the call, partly notifying the hospital)
- our vehicles with all the equipment
- news
- checklists and SOPs
- hospitals in our area
Resources during a flight include, for instance:
- the pilots and the cabin crew with their knowledge, skills, and attitude
- the airliner with all the equipment
- information on the weather and maps (of the routes and detailed maps of the airports)
- air traffic control in the tower and during the flight
- possibly technical support on the ground in case of malfunctions
- support on the ground in case of medical emergencies (f. ex., information on hospitals at certain destinations along the route)
6.2. Which of the First Five Key Points Are Interrelated?
Knowing the resources also means knowing the environment (1.). As further teams, which we can call to the scene, help us, also the third key point applies: Call for help early, better early than too late. If we receive help from further resources we have mobilised, we, in turn, distribute the workload more wisely. Hence, also the fourth key point applies: Distribute the workload.
6.3. What We Achieve Using Our Resources
After having visualised our various resources, we will summarise briefly what we achieve when mobilising them, also in the light of key points 1., 3., and 4.:
- a safe and timesaving workflow as we don't have to think about and look for items long
- due to this safety, we have free capacities to handle complex situations
- we know how to use the resources in the complex situation advantageously (f. ex., our hands and heads, equipment, checklists and SOPs, as well as additional teams)
- we know, where we find help and distribute the workload among all available persons
- hence, we reduce stress in the complex situation
- we minimise the risk of errors due to the safety and reduction of stress
6.4. The Limitations of Our Resources
Despite of all our knowledge and skills, and despite of all the items we have at our disposal during a call, our resources have limitations, which we should know quite as well. For example, the medical treatment, which we can offer at the site or en route to the hospital, is limited.
7. Communicate Effectively - Speak Up
There is a lot to be communicated concerning this key point. Thus, we will limit ourselves to the emergency medical service as an illustrative model. Communication is more than a principle in CRM, it helps us to use all the CRM principles as a team confidently.
7.1. With Whom Do We Communicate?
Already here we can mention many items:
- within our team, with all teammembers
- with other teams (dispatch, the police, the fire department, amongst others)
- with our most important teammember: our patient
- with the relatives (they are concerned, they provide us with and need information)
- with the hospital (is there a bed available, the patient's condition and the diagnosis, discussion of potential further measures en route, changes in the patient's condition en route)
7.2. What Do We Communicate?
You may well imagine that we communicate just the facts during a call. This, in turn, helps us to maintain our focus and, for instance, not to overlook a piece of information. We will deal with information as such when we reach key point 8.
We might discuss the following items:
- whilst en route to the scene, all facts that are known already, such as the weather (accidents, availability of a helicopter), potentially additional emergency services
- in a structured manner, the team, which had arrived at the scene first, will report what it has found out about the patient so far
- we discuss all relevant information, such as the present condition, and the vital signs, previous medical history and the medication regimen, as well as allergies
- we decide on our actions and distribute the workload
- we communicate all of our measures to the patients and, if applicable, to the relatives
- we discuss with our patient and the relatives the hospital in question, as well as, for instance, how to contact it and the possibilities to visit the patient there
7.3. How Do We Communicate?
First and foremost, we stay calm and communicate matter-of-factly. Without becoming hectic or raising our voices, we discuss pieces of information, distribute the workload, and their execution will be reported back. We should try to speak clearly and understandably, and to use technical terms precisely.
We should explicitly address teammembers by their names and wait until we have their attention. In addition, we should realise whether the team is being occupied with a task in a highly concentrated manner. It is not very sensible to mumble a blood glucose level with a lowered voice, when the three other teammembers are busy studying the ECG intensively.
7.4. Important Communication Techniques
If you have been reading along industriously so far, you are already perfectly familiar with closed communication loops, and the speak up, standard phraseology, and the sterile cockpit rule.
As communications serves as a connective link in CRM, it is intertwined with all the other remaining of the 15 CRM key points.
8. Use All Available Information
Using the emergency medical service as an example, we will discover from how many sources information can come almost simultaneously. Thus, we will subsequently shed light on how to structure the information in order to master this complexity.
8.1. Information from a Wealth of Sources
- we obtain the initial call as well as first pieces of information from dispatch
- auf der Anfahrt kommen eventuell erste Rückmeldungen vom ersten Team vor Ort
- having reached the patient's place, we learn about the current symptoms and the vital signs
- the patient and her relatives report to us the past medical history, allergies and medication, partly spontaneously, sometimes simultaneously to different teammembers, sometimes upon enquiry
- physician's letters, medication regimens, as well as different types of medical passes (for example, pacemaker, implants, diabetic's diary, documentation of blood thinning medication) are presented to us, often whilst another teammember gathers vital information together with the patient
- we ask to what hospital we can take the patient and may receive additional information or alternatives
8.2. How to Structure the Information to Take All Items into Account
As we have mentioned above concerning the emergency medical service, we receive some pieces of information simultaneously. Now, we need to structutre it to make sure that we have all the facts we need, to classify them according to their importance and not to overlook relevant ones.
A fixed scheme may help: current symptoms, vital signs, then the previous medical history, allergies, medication, further information. If appropriate, everyone can create a short checklist and run through it in his or her mind.
8.3. We Use the Information
Using the information, we will now make decisions. What needs to be treated in what way? According to the complexity, we may perform a team-time-out and use a structured model for the decision-making process. Following that, the resulting tasks will be assigned.
The information we are now using, is, in turn, a resource which we apply.
8.4. What Can Happen if We Omit Pieces of Information?
If we forget to obtain a piece of information or it gets lost whilst the team is concentrating on a task, this may have several consequences. We may, for instance, overlook a condition which needs treatment, such as a low blood sugar level.
We might miss an allergy and apply a medication which our patient must not receive under any circumstances. The same holds true with respect to contraindications and potential interactions with a medication which the patient takes regularly.
An ignored or not actively obtained piece of information may also lead us to create a false mental model of the patient's condition and stick to it, although it is wrong. When we look at the low blood sugar level again, which may cause a seizure-like event, it would not be the first time that a team now an administers antiepileptic medication instead of eliminating the cause with glucose given intravenously.
A false mental model is one type of a fixation error. Fixation errors are treacherous, as we will discover in a minute. Hence, a distinct key point was dedicated to them.
9. Prevent and Manage Fixation Errors
9.1. The Very Human Fixation Errors Creep in Easily
A false mental model, which means an imagination of a situation in our minds, which does not correspond to reality, may be due to ignored pieces of information or due to those, which we have adopted from others uncritically.
We may overlook information if we don't work diligently enough, which is a matter of attitude, but also if we are interrupted and distracted.
Futhermore, the following example illustrates one mechanism of a fixation error.
9.2. An Example of a Treacherous Mental Model in the Emergency Medical Service
An alcoholic homeless person falls repeatedly from the same park bench, and helpful passers-by call the emergency medical service time and again. Also on this chilly morning the rescue team thinks: "Of course, he is drunk once again." What consequences follow, though, if he is suffering from an intracranial bleeding this time?
Such a diagnosis is very likely if the alcoholic patient is malnutritioned and has a compromised liver function, so that the clotting factors are not produced in sufficient quantities by the liver. Additional causes may contribute, for example, a foregone fall.
The patient with the potential intracranial bleeding is in danger of death. Hence, the team must act accordingly and carry out primary care adequately before taking him to the appropriate hospital in which such a bleeding can be diagnosed and treated.
As fixation errors are so human and happen rapidly, we need to be particularly aware of them.
9.3. How to Deal with Fixation Errors
As we have seen in the example above, we should never be too lazy to question our mental model of the situation. We should not be misleaded by the simplicity of quickly applying a well-rehearsed standard procedure.
We should keep our critical view and ask our team about how it perceives the the situation. As teammembers, we should have the courage to object to something if we have noticed a mistake in the mental model.
We should, if necessary repeatedly, double-check the information which we have used to underpin our working diagnosis and decisions. This leads us to the tenth key point.
10. Cross and Double Check (Never Assume Anything)
10.1. Discrepant Information from Different Sources Almost Cause a Mid-Air Collision
The near mid-air collision of two airliners of the Japan Airlines on January 31st 2001 shows us the severe consequences discrepant information may have. As the two aircraft came closer to each other in the air, in both of them the integrated traffic alert and collision avoidance system (TCAS) advised the pilots to change their flight level in a coordinated manner.
Additionally, the crew in the cockpit of the Boeing 747 received the exact opposite direction from air traffic control. The crew decided to follow the air traffic controler's instruction without communicating the discrepancy, which led to the near mid-air collision. In the course of the investigation of this incident, it was determined that in such situations pilots always have to follow the instructions they receive from TCAS.
10.2. In What Situations Should We Cross-Check Pieces of Information?
We should carefully cross-check the information if:
- we receive information from others (f. ex., is the side of the body where the injury occurred correct?)
- we where interrupted in our workflow (have we really absorbed all of the information?)
- there are different specifications from several sources
- we have a gut feeling that something is wrong
- we receive many pieces of information at once in a complex situation
- everything of which you can think
10.3. How Do We Carry Out a Thorough Cross-Check?
Especially in the situations mentioned above, we should cross-check our sources carefully. What information is plausible concerning the actual situation? What does not fit in? Why? Have we got the possibilities to obtain more information? During calls, we have already phoned general practitioners, or a hospital in which the patient is already known, to enquire about previous diagnoses and treatments.
We ask our teammembers how they perceive the information and what they have observed. Have we overlooked anything ourselves?
If we cannot find out what information is correct despite of all our efforts, we assume the worst case and act accordingly.
As we have already mentioned, the thorough cross-check of information, especially when it comes from different sources, is also a tool to prevent fixation errors.
In the Next Blog Article We Will Cross the Finishing Line
... at least with respect to the theory of the 15 CRM Key Points by Rall and Gaba. In practice, it will become really interesting as it takes much rehearsing to really remember them in complex situations and act according to them.
In order to finish this series, we will occupy ourselves in November with how to guarantee great teamwork, and apply mnemonics, how to direct our situational awareness deliberately, how to reevaluate the situation continuously, and how to set our priorities dynamically.
Once more, we will realise how the 15 CRM key points are intertwined and what the purpose is.
Author: Eva-Maria Schottdorf
Date: October 29th 2022
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