So now that we’ve talked about the basic premise behind recognition primed decision making, lets go to step 2 – how do you train people when good decisions are based on experience?

If you don’t have experience, then you won’t have a database of cases and scenes in your head to compare to new situations and past plans to choose from to create new plans. If all you need is experience, why spend all the time learning fundamentals, biochemistry, flow dynamics, etc.?

First, in complex situations, you probably could be an adequate practitioner if you just went through 1,000 simulated or real life situations, critically looked at what went on, threw away the bad ideas and kept the good ones, and then moved forward. Unfortunately all your acumen would be based on previous situations and how they came out, you would not have the background to adapt to alterations in new situations, and it would be harder for you to remember what to do under pressure, without some fundamental knowledge of how things work. If you wanted me to be a fire ground commander, or you wanted a master sergeant in the army to be a surgical intern, you could probably accomplish both goals by giving both of us tons of situations, describing the presentations, going through the decisions, and what cues were used to make them, and then go over the action plans, what worked and what didn’t, and putting us both under and apprentice period of close observation. We both would probably not absolutely need the background knowledge, and we would be able to handle most simple situations, but we would have little capability to react to new situations. So our eventual competence would be limited by only what we’d been taught, and what we experienced personally.

So you need some background fundamental knowledge, and real cases, carefully presented and taught. But I believe a training program where you present 90% background scientific fundamentals and 10% demonstration of real life decision making is a lot less effective than 25% background and 75% real life cases, simulation, and apprenticeship.

So when you’re trying to teach new people, or trying to improve the performance of experienced people, it is ESSENTIAL that you focus on those aspects of the call, case, or fire that would have prompted you to move in a different direction than the other person did. Did you see something they didn’t see? Did you put more emphasis on one piece of data? Did they they not recognize the importance of a group of data? If you dont dissect out those issues, then they will not know where their mental model went wrong and they will just make the same mistake again.

Very interesting paper in New England Journal of Medicine (NEJM 2009;361:1368-75, Variation in hospital mortality associated with inpatient surgery) that hospitals have widely variable mortality rates, but surprisingly very similar complication rates. What seems to differentiate great hospitals from good ones, is the ability to rescue patients from complications, not preventing complications.

This is a very important finding, because rescue, in hospitals, is often neglected. We assume that the same nurses and staff that perform routine daily medical care, can immediately transition into providers that can handle the rapidly changing variables present in a patient who is declining or crashing. Often saving a patient with a major complication requires aggressive resuscitation, thorough and rapid search for a cause, and immediate intervention. Another problem is that these patients often look “sick” but dont look like they are “dying”. By the time they look like they are dying, it is often too late to effectively intervene.

Also you could gather 10 patients with sepsis, and they will all have different symptoms, vital signs, and lab data. It takes an experienced caregiver, with a very healthy paranoia, to intervene correctly in these situations. Another maxim of rescue (in hospital and out) is the acceptance of over-reaction. I have talked about this before in that the fire-ems community accept a rather large percentage of calls where they “over respond” based on the eventual facts of the situation. Hospitals are only now learning the importance of over-reaction, and the fact that if you are going to catch the 5 patients who are dying from a complication, you may need to vigorously intervene on the 20 patients who just “look like something is wrong”. Waiting until those 5 patients declare themselves as “really sick” will likely eliminate your opportunity to save all of them. Thus, over-reaction will save lives.

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.