Recognition primed decision making – Step 2

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.

Case presentations: SBO -Hemothorax – Lower GI Bleed

Case #1

These are cases presented to me as the student without seeing the cases previously. I am also including the post cast discussion with Joe Sills who wrote the cases. The x-rays you hear me examining are to the right. The CT is for case #1, the CXR is for the trauma patient in case #2. Hope you find it helpful

JY

Recognition primed decision making

In the paper I posted by Gary Klein, they show the evidence, and discuss the background to their decision making model known as “recognition primed decision making”. I know many of you are not going to take the time to read the 100 page manuscript (but I highly recommend it, I’m rereading it now and its great), so I’m going to go over some if it. Sorry  I haven’t my podcast on this, but there have been some scheduling issues.

First, Klein says (and I agree) that when an experienced operator, in whatever high-stakes field, encounters a situation (fire, patient, etc.) they do the following:

– Size-up the situation in their mind, assigning it a “schema” based on their previous experience

Explanation: In your mind you record experiences you have had in your profession. With time you categorize those experiences into “boxes” or “schema” of similar situations. In other words, when I see a 80 year old trauma patients on inhalers at home who has 8 right sided rib fractures, I don’t make my clinical decisions based on each of those datapoints individually (elderly+/COPD+/-rib fractures+/- etc.), do it by matching the case to schema I have already created. For this it would be: “old patient with lung problems and big non-lung chest injury”. Then my mind automatically jumps to what I have done for “old patient with lung problems and big non-lung chest injury” in the past and how things have worked out. My plan is based on those past plans and results.

–Make a plan based on how patients with this schema have done in the past

Thus my reaction is: “ICU, pulmonary toilet, check if on steroids, try to find previous assessment of lung function (and get ABG to assess current), pain control (with epidural), get out of bed, incentive spirometry, check for wheezing, give inhalers, DVT prophylaxis, watch out for increasing oxygen requirements, check chest x-ray”. That may sound like a lot, but its pretty automatic and doesnt require much thinking, because I’ve taken care of so many of these patients. Why do I have “watch out for increasing oxygen requirements”? Because in my past, we didnt do that and its worked out badly. “Give inhalers” – same thing, at one point we probably forgot to do that and the patient got intubated. Etc.

–Keep an eye out for data that conflicts with schema, or which indicate plan isn’t working

This is the sign of an experienced provider, inexperienced people are so happy they came up with a plan that they tend to fixate on it, and don’t accept new data that says their plan is wrong. That’s why new officers and residents need to be watched like hawks. They will tend to push a plan through, even though new data is indicating the plan is not working. It’s not just experience, but ego. Experienced leaders know that things go wrong, and you have to adapt. Inexperienced leaders think changing the plan is an insult to their ego (which is fragile as a new leader anyway) and try to  make reality adjust to the plan, not adjust the plan to reflect reality.

This is just an intro to these concepts. Think about them and we’ll discuss examples from Klein and real life in the next post.

JY

 

 

Practice makes better

A discussion of using war games and cognitive simulation to better prepare you and your team for new situations. Also a discussion of active shooter MCI and the importance of communication with the hospital in these situations.

Welcome to new sponsor Orange County Fire and EMS!

Thanks to Tom Joyce and Orange County Fire and EMS for being the first sponsor of Clinicalbraintraining.com and Fire-EMSbraintraining.com. We’ll try to make their investment worthwhile.

Cardiac Arrest from Trauma

The right thing to do with trauma patients that come in arrest, or near arrest can be difficult to figure out. The generally accepted, evidence based rule for this is that for victims of penetrating trauma, they must have had vital signs when EMS arrived (found dead, stays dead), and should not have been in full arrest for more than ~10 minutes (with CPR). For blunt, the patient must have had vital signs of some sort (a pulse at least) in the ED, or within a minute or two of the ED. Even with loss of vital signs at the entrance to the ED, the recovery to discharge rate is abysmally low.

But, EMS often breaks their backs with these patients, doing rapid extrication, ALS, CPR, and priority red transport, and it always feels wrong to just pronounce them on arrival when we stop CPR and find no pulse and fixed dilated pupils. I hate to admit it, but I have done resuscitative thoracotomies in these patients, when I know very well there is no chance of survival. Often, making sure the airway is in, putting in bilateral chest tubes, and a shot of Epi is enough to make everyone feel we’ve tried in the bay, but it’s really just going through the motions, since none of that will resuscitate a trauma patient that has bled out.

I think its important for all trauma surgery, ED, and EMS providers to know the real stats on trauma arrest. I believe the highest discharge from hospital alive rate in penetrating was 7% when arriving in full arrest (some studies are higher, but if you read those carefully, a number of patients were not in arrest, but were just hypotensive), and I have never seen a discharge from hospital rate for blunt arrest over 1%. We have had discharge alive in blunt patients who arrested in the ED, but these patients arrived with vital signs, and lost them in the ED in front of us, making return of circulation and aortic clamping almost immediate. Even with that, the vast number of patients with trauma who have arrested in front of me do not survive.

To make the right decision, you need to know the data.

JY

War Games Cases – Trauma/ED/ICU

Here are three recorded war games cases presented with me as the student by Joe Sills, a medical student who worked with me. It allows you to hear what I do with unknowns, and how to work through the data to create plans. Thanks. JY

Gawande’s article on Cheesecake Factory

Atul Gawande’s article asking why Cheesecake factory can provide outstanding products in diverse environments, at reasonable prices, and why we cant do this in hospitals has been sent to me by 5 people. The theme is “why cant we do this?”. I have several comments:

First, I respect Gawande tremendously, but there is a big knowledge gap between doctors who practice medicine, and doctors who attempt to control the way other doctors practice medicine. Gawande is in the former group, and I am in the latter. It is easy to identify the problems in medicine, but much harder to devise and implement solutions.

Second, the line cooks, waitresses, managers, and other employees at Cheesecake Factory accept their positions knowing they are joining an enterprise where their individual initiative is neither wanted, nor needed. I am fairly certain Cheesecake Factory isn’t looking to hire Thomas Keller as a chef. They want people that will easily fit into a system. They are rapidly indoctrinated to a system of processes that have already been figured out. Since, the processes are known and vetted, they are relatively easy to implement in individual restaurants, and in restaurants in different states, or countries. In addition, they have concrete data to represent their success and failure. Sales drops are easy to identify, as well as products that don’t sell, entrees with excessive production costs, and ingredients with high acquisition costs. This data can be operationalized immediately, without argument. That allows the restaurant to be nimble in response to market forces. In medicine, we have few if any vetted and conclusively proven care processes. Sometimes I wonder if there is anything we do that we can definitely say is the “best” way to do it. You only need to look at appendectomy (laparoscopic versus open), CPR (ABC now is CAB), angiography for vascular disease, CABG versus angiography, etc., etc., etc. Sometimes the lack of definitive data for so many things leads to the creation of care guidelines that turn out to be flat wrong, when new studies emerge. At Cheesecake Factory, if they sell a lot of something with a high margin, its awesome, if they dont, they stop making it. We dont have that option.

And finally, Doctors. We are all people at the top of our classes most of our lives, and then went into a profession where we were taught the ultimate responsibility for any adverse outcome was our fault, not the fault of the system. We question and object to data, refuse to follow guidelines because there “might” be a patient that would come along that would be hurt by the guideline, and don’t accept that there are some parts of medical care that others (NPs and PAs) do just as well as we do, if not better. Nevermind, the cottage industry nature of each medical practice where you are responsible for generating income to support you and your family. The more work you do, the higher your income (in general). A manager or chef at Cheesecake Factory does not possess these attitudes, or if they do, I am fairly certain they do not have the power to run their line or restaurant however they see fit. Doctors can, in general, run their clinical practice with a great deal of latitude.

Pointing out how far we have to go in medicine is no longer helpful. Anyone who doesnt realize that change is necessary has been asleep for the past 10 years. We need solutions that take into account the nature of medical care in it’s true state. Success in changing and controlling medical practice occurs when all involved realize they need to find a path that decreases variability, costs, and adverse outcomes.  First you need to identify care processes that are optimal (given the current state of knowledge), then you need to have information and control systems that make it easy for practitioners to comply with the recommended care processes, you need to provide feedback as close to real time as possible, and then you need to constantly look at your outcomes to make sure you are not hurting anyone. It’s a tall order, but it requires everyone to be on the same page.

Dealing with uncertainty in the middle of the night…

A discussion of the tension between cost containment and the need to prevent unexpected negative outcomes. Some patients do not have a sign on them saying “I’m sick, intubate me and take me to the ICU”. Sometimes the signs are much more subtle, and will not be appreciated without a high degree of suspicion and paranoia.

Fire-EmsBrainTraining.com

Friends,

Ive found it hard to design podcasts to appeal to everyone in and out of the hospital, so I started other website Fire-EmsBrainTraining.com. The site is up right now.

I’m transferring some of the EMS focused material to that site, and hope to get a lot of help from my fire and ems friends for guest postings and podcasts.

The link is on the blog roll to the right.