dasSMACC Day 2- Pik keeps talking…and talking…

Panel: Walter Eppich, Jesse Spurr, Liz Crowe, Carol Hodgson, Ashley Liebig, Sandra Viggers

This round took off on a completely different note.
Opening with a multidisciplinary panel, the group took on tribes and how they affect the functioning of the team and interprofessional practice. Nearly all members of the panel offered both pros and cons to the existence of tribal groups.
Tribes offer a sense of belonging to the group and instill new members with a shared culture. They can encourage the creation of a close knit team with a shared mental model. If your team assembles like a flash mob in response to a notification with a critical patient, ie. most emergency departments, then this can be invaluable.
On the other hand, one thing that creates a bond within a tribe is the existence of a common enemy. But there are significant downsides when the common enemy is another tribe. Communication, handoffs, and treatment plans can all suffer when battle lines are drawn between professionals. A simple introduction by name does a lot to break through the tribe and humanize an “enemy.”
The panel offered personal anecdotes and called for all of the members of a tribe to create a culture of inclusion. The highest and most functional tribe no longer needs an enemy tribe, it organizes around a higher purpose, a shared vision. Rather than protecting our own in conflicts from opposing tribes (subspecialists, consultants, admitting attendings…) the tribe now sees human suffering as the enemy and draws cohesiveness from this shared purpose.
One theme that was reinforced here and continued to be referenced was “fundamental attribution error.” This is our tendency to judge others by their actions, but ourselves by our intentions and internal dialogue. So when a member of our tribe is short tempered with the team, they are excused due to fatigue and stress. But when a member of a different one performs the same action, they’re an asshole. Cue comment about surgical consultants, but be aware of how you’re lumping all the members of the specialty together and casting them as the opposition to be overcome. Beware of FAE!
Finally,we create our own culture, and it’s not just top down from our leadership. Every member of the tribe reinforces the behavior. As a member, every time you resist the temptation to throw someone outside your tribe under the bus, you are normalizing a new code. Ultimately this is better for our work lives, our trainees, and most importantly for our patients so that we can ensure the medical team can provide collaborative, holistic care.

Ashley Liebig, Chris Hicks, MJ Slabbert

The other theme for me on Day 2 was a thread through several of the talks.
It began with Ashley Liebig who built on the tribe discussion that had preceded and argued that nurses should “Rule the Resus Room!” Nurses are trained ACLS providers, and are recording and documenting drug administration and doses. Many tasks that the senior physician assumes when acting as “team leader” are ones that a nurse provider is well suited for. This can free the physician to engage in higher level monitoring and improve their cognitive load. Ashley argued that this approach broke down the tribes of nurses and doctors into a common group in service of the patient.
Chris Hicks took on a difficult topic, Making the Complex Simple. A cerebral talk that referenced the Kolmogorov complexity (no, don’t bother to google it) and drew on systems theory to break down a terrifyingly complicated patient presentation into an algorithmic response. He drew a distinction between complicated and difficult, saying that a simple approach requires clear thinking and deep mastery. “If you can’t explain it simply, you don’t understand it well enough.” He also destressed the value of the “Goal” over the “How to get there.”
His 4 main points were:
  1. Habit: the power of valuing processes over performance. Practicing a response to a scenario and standardizing a team approach provides a shared mental model and quality control. This seemed to echo Ashley’s encouragement of a structure that improved cognitive load, allowing teams to better respond to complex and fluid circumstances.
  2. Emergent Order: how to reorganize your teams to maximize productivity. This is a semi-independent creation of mini-teams that address the key elements in a complex situation. 3 sub-leaders addressing airway, access, and secondary survey might emerge in response to a trauma.
  3. Factoring Down: here’s where the Kolmogorov complexity comes in. Basically, how to make a complex situation as simple as possible, but NOT more simple than is necessary. Look up Einstein’s actual quote on the topic if this is still unclear (not the Pinterest version!). Having a team leader focus on a mid-point goal, or a few key critical actions can keep the team’s shared mindset and situational awareness intact.
  4. Limiting Variables: This seems like it’s the same thing as factoring down, but it’s very different. Whereas factoring down is a mental model, limiting variables creates a system designed not to fail by offering simplicity. Does your shop have a cricothyrotomy kit? Mine does. Does your kit contain more than 3 or 4 items? It can likely be simplified. Train your team and look for opportunities to limit variables, from equipment to phone calls to clicking orders into a computer.
While his vision seemed to support Ashley’s model at first, I began to question how fluidly a team could adapt if the RN running the code ran into an MD utilizing his freed up cognition to deviate from “proper” ACLS. As this is not an uncommon occurrence, I wondered if there would be specific RN roles in the emerging order or if the RN/MD boundaries could truly be blurred.
MJ Slabbert gave a powerful presentation on decision-making, and I was left with another mental framework of the more rigid or protocol-driven approach in tension with a more fluid anti-algorithmic approach. She offered a trauma scenario which was far from typical and not lending itself to easy answers. What would you do with a GSW victim, shocky and sick? If no immediate airway issues, this patient needs an OR eventually. But should you take time to do hemorrhage control at the scene? Did we mention that you’re at the top floor of a walk-up with a very narrow staircase? (A later panel of sages would advise to “Stay and Play” unless requiring a definitive endgame (ie. cath lab).)
Dr. Slabbert cautioned against disregarding gut feelings when they conflict with protocols. She made the point that protocols are only a starting point, and while providing good scaffolding for a novice, experts routinely deviate from them. We shouldn’t be afraid to factor in our instincts or emotions into the equation and often will have to improvise new algorithms in complex situations. Again this seemed to echo Dr. Hicks’ talk but veered into the realm of naturalistic decision-making, the typical cognitive paradigm of experts. The question of how experts confidently go wrong and how to balance algorithms against improvisation looks like it will get taken on tomorrow.
Send comments with questions!

Written by:



Program Director, LIJ Emergency Medicine

Dr. Mukherji is the Residency Director at LIJ Medical Center in New Hyde Park, NY.  He spends most of his time confusing residents and trying to convince doctors that they overestimate the benefits of treatment and underestimate the harms. He has a passion for education and trying not to do things wrong

Edited by:

David Marcus, MD

David Marcus, MD

Editor in Chief, theEMpulse.org

David is the Residency Director for the Combined EM/IM and EM/IM/Critical Care programs at LIJ Medical Center.  He is also the Editor-in-Chief for theEMpulse.org.

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