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All posts for the month May, 2012

Teaching How to Do Scenarios and How to Learn From Them (BACKGROUND FOR THIS WEEK”S PODCAST)

 

While checklists are good, teaching  people to perform medicine where 100 proscribed motions and words are delineated may or may not be good. While seemingly contradictory to what I’ve said before, here are the reasons:

Memorization sucks from a safety perspective

  • Things are memorized in patterns, when you break the pattern everything shatters to the ground and its very difficult to recover
  • So, memorization is good if you can sit there, clear your mind, concentrate without interruption, and regurgitate the components – rarely happens in an emergency

Memorization is a bad way to teach

  • Things are learned in chunks (5-7 individual items) that are then bonded together by transitions
    • Airway transitions to breathing exam after you do X, breathing to circulation when you do Y
    • That way all you need to remember under pressure are the transitions, the chunks will be there for you if you learned them properly (repetition)
  • People who are not good teachers (or think they are good teachers) teach neophytes by pointing at the list of checkboxes and say “look, dummy you didn’t do this one”. The learner then gets nervous and goes “shoot, I better remember to do that one” this then makes it hard for them to remember the previous step or the one following since they now fixate on the one they missed.
  • Checklists are NOT FOR MEMORIZATION. They are safety tools to be used during, or around the heat of the moment to create a situation where you can collect data, analyze, and implement. When you don’t have to memorize, you can go one level deeper into information gathering and analysis, which is usually good (but could be bad if you are not diligent about going back to your checklist and making sure you got everything).

So if you have a checklist why learn anything?

  • Because you need to understand the physiology, the presentation, the sequence of signs and symptoms, the safety considerations, the techniques for care (IV’s, intubation and such) and you need to learn how to properly rank priorities and form and carry out a treatment or rescue plan that works.
  • The checklist merely allows you to not forget essential safety components

My take on how to teach this:

  • Make certain the learner understands the background on everything (what it looks like, what its components are, etc.)
    • What respiratory failure is
    • What an unsafe environment is
    • What shock is, etc.
  • Next, insure they understand why the steps in the algorithm are where they are?
    • Why is airway first
    • Why do we listen to the lungs
    • Why do we check peripheral pulses first
    • Why do we wear PPE
    • Why is an unsafe scene a problem, even when the patient is dying and needs help right away
  • Next, ONLY practice the individual steps.
    • Do those until you can see the person understands what they need to do and why, and why the algorithm is the way it is..
    • Don’t even think of going to step B until they have a grasp on step A
      • Example: don’t move to breathing evaluation until the learner is checked out on airway, and so on

After learning all the steps (airway, breathing, circulation, vital signs, etc.)

  • Use YOUR experience and knowledge to help them link the steps
    • Everyone does this a little different, and often there is no right way
    • Will go over in podcast

When you are preparing to test, don’t make them go through the whole evolution if they are screwing up – STOP! You must correct them when they muck up a step or a transition

  • How you prepare someone for testing is where your ability as a teacher comes out. It is at this step you can make or break learning and retention
  • Remember, in these sorts of things, if they do it wrong once and their mind grabs that bad process, it will take a lot of work (usually 5 perfect repetitions) to eradicate it
  • Stop, tell them what they did, and go back at least 2 steps, so they need to practice the step, and the transition in the flow of the problem.

Finally, testing probably needs to be less strict

  • I know this is contrary to a lot of what I say, but if someone is getting nervous at the same step in the test over and over again, and they clearly understand the material, and they do everything else right, they probably are competent and shouldn’t be failed. If they are horrible all the way through, get rid of them before they hurt someone.

In this podcast, I try to tackle the issue of leading clinicians to safer and more effective care. I give no answers, but my take on the process from my experience in quality and patient safety. Whether you are a leader or are objecting to being led, I think you will get something out of it.
Music from Tom Jolly and I from the album “On Call” from our old group Nightbreeze.
Thanks
JY

As I’ve said in the podcasts and posts, improvising off the top of your head in high risk situations usually doesn’t work out well for anyone. Yet, sometimes you see people respond effortlessly, when circumstances take a rapid turn for the worse, and you think “wow, they can really think on their feet”. There are probably two things going on in experienced people’s minds in those situations.
First, they have been through the situation before, and if you looked at some of the posts, and lectures, you know that when you go through situations multiple times, you create a “model” or “schema” in your head for that situation. That means that your brain goes “ok I’ve been through this, that looks like it did before, that does also, last time I did this and it worked out, I’m going to do that again”. A really experienced person also adds “I’m going to watch out for X, because if that happens, I’m screwing up and I need to change to plan B.”

That works well for people with lots of experience who have worked their way through a lot of situations, what do you do if that’s not you? The key is “mental war gaming” and thinking a few steps ahead, and thinking “what if this is going on?”. Ran a call with the firefighters recently where a child was not responsive after a seizure. I felt the child was OK, but my brain immediately said “check the pupils, check the oxygen sats, and keep a close eye on the breathing” because I’ve been in situations where children have looked OK, but 10 seconds later their lips are blue and they are in respiratory arrest. So if the pupils are equal, the breathing is steady, and the sats are OK, I relax a little. But I also said to myself “what if he stops breathing, or his sats are 80%?” and I began looking for where the bag mask, and peds mask are, where the airway equipment is, and when the transport unit is getting to the scene. You also start playing in your head “if he’s not breathing, what am I going to grab first, are we going to try to ventilate him where we are, or move to a better spot, are we going to let the incoming unit know?, what if we cant bag mask the patient?”, etc.

I was thinking those things, but later I was mad at myself because I was lazy. As soon as I saw that the patient was unresponsive, I should have found the airway equipment, and had it in my or the medic’s hands. I should done that because I also know that if something bad happens, it’s a lot easier to have the stuff you need right in front of you, rather than just thinking “I know what bag that’s in”. This is especially true in the trauma bay since it takes someone else to get the equipment and set it up, leading to an even longer delay. It’s always better in the bay to have the equipment out, on a table, with everything you will need already pulled. Then when you need it you just need to open the packinging and get to work.

Clinical brain training makes you a better provider. Its easy to do on any call or hospital situation, and provides you with constant mental training for when a big situation hits.