Heroism vs Safety:please sir, may I have both ?

Peter Brindley MD FRCPC FRCP-EdinFull-time Clinician, and proud of it

Other Stuff: Professor: Critical Care Medicine; Ethics;

Anesthesiology

Division ofCritical Care Medicine

Declare your biases I

Prof Julian Bion

Physician def’n:• “A physician is a healthcare worker

authorized to work outside of guidelines”

smacc

Medicine: the most humane of the sciences;

the most scientific of the humanities

E Pellegrino

Declare your biases II:

smacc

The cold-hard truth (baker CMAJ 2004)

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Medical Auto Workplace Air

Deaths

A ZivWith permission

“Completely preventable ”

Neglected?

Brindley ‘10 Crit Care; Brindley et al’14 Can Resp J

“Care Gap”“Expectation Gap”“Education Gap”

“Science of managing complexity”

180 steps/pt/day

“Too much plane for one man to fly”

A Gawande, P Pronovost, many others

“Science of team performance”

# Steps Probability entire process correct

1 0.9525 0.2850 0.08100 0.06

LL Leape 1994; IHI. Preventing errors: the role of complexity.Pronovost PJ

“fit for task”?SIMPLE COMPLICATE

DCOMPLEX

EXAMPLE Bake Cake Fly to moon Raise child

PREDICTABILITY High Medium Low

EDUCATION Learn/ Practice

Break into steps

? Experience

STRATEGIES Task trainer Simulation ? Experience

Zimmermann and GloubermannA Gawande. Checklist Manifesto

“Engineering” Medicine

Reliability/ Resilience• S.O.P; Fail-safes

Knowledge exceeds the individual• Craftsmen Guilds Process engineers

Human factors, Team training• Engineering pressure tests a system-Simulation

Brindley P.G Crit Care 2010Brindley P.G ISICEM Yearbook 2010

W Dunn Chest/ D Angus/N Gibney communication

Human Factors, Crisis Management, Team

Work

Brindley. J Crit Care 2010

Personality

Team

Culture

Skate to where the puck will be

www.skygod.com/quotes

berkeley.edu/news/berkeleyan/1998/0225/coley.html

“it’s amazing how much you can achieve when nobody cares who gets the credit”

Culture Reinforcement

Which team do patients need?

“Team of experts is not an expert team”

• Obedience• Milgram & electric shock

• Conformity• Asch

• Play a role• Zimbardo & Stanford Prison

• Performance in different-sized teams• Dunbar

“Miracle on the Hudson”

“Sully Sullenberg”

“Captain America” “Hudson River Hero” “Le Nouveau Heros de l’Amerique”

The Pilot Not Flyingfewer planes crash when copilot flies

A Gawande 2009

PATIENT

Surgeons Physicians

Respiratory Therapist

Family Spiritual services

Pharmacy

“Medical Ergonomics”

“Ectopia”: land of danger

De Vita et al. & Trauma.orgS

L

A

S

S

Attudinia: equally dangerous!

• “Too early; too late”– The 7 yr hangover

• Hit the target; miss the point– Mid-Staffordshire inquiry– Elaine Bromiley

Brindley and Berger: J Crit Care 2009

Deep Blue(aka

Technology)

Garry Kasparov

(akaHuman)

• Pilots so reliant on computers…“they are forgetting how to fly”“automation addiction”

• 60% accidents; 30% major incidents

J Orr Aug 2011

Teaching beyond checklists?

“The blind learner”: a unique addition to CRM Brindley J Crit Care 2008”.

Flex lower c-spineFlex lower c-spine

Extend OA jointExtend OA joint

Ears in front of sternumEars in front of sternum

Sniffing posSniffing pos’’n n 1936 Magill 1936 Magill

Really?

Anatomic…………………………37% correct Sniff ……………………………….15% correct Win with the Chin………….43% correct Control…………………………… 20% correct

”Win with Chin” significantly better than sniff

Brindley et al. BJA 2010

Any Evidence?

A BIG BUTT

“SNIFF THE AIR” MADE YOU WORSE

5 cultural dimensions Geert Hofstede

Power distance index Inequality;

Individualism“Me” vrs “We”;

MasculinityAssertive;

UncertaintyRules vs Style

Long term orientationPersistence;

• “Culture eats data for breakfast”– Peter Drucker

Patient Safety vs Heroism 2.0

…What do patients need?

A.Factual Knowledge?B.Procedural dexterity?C.Communication/team

skills?

“Being an expert clinician means being an expert

communicator”Down a

bit

Up a bitStop!

In a bit

“You cannot NOT communicate”

“Meant is not said

Said is not heard

Heard is not understood

Understood is not done”

“Close the loop”

“Sterile cockpit”

“Mitigating language”

“levels of advocacy”

“Repeat back method”

“SBAR”

Cyna et al. Handbook of communication. 2014.Brindley. Can Resp J 2014

BETTER WORSE

Our most dangerous procedure!?

Many thanks