In 1924, W. Wayne Babcock, MD, FACS, raised a critical question: “How efficient a lifesaving station have you in your operating room? Is it safe for me to collapse or have respiratory or cardiac arrest while undergoing an abdominal operation under your care?”1 Nine decades later, the answer to this question still seems elusive. If one queries his or her surgical cohorts regarding their ability to lead a team through an in-operating room crisis (IORC), the typical response is a boastful rendition of exemplary leadership of teams through any crisis. However, surgeons frequently rate their own ability to lead a team higher than their teammates do.2-4 Recognizing the limits of surgeons’ leadership skills in routine, non-threatening circumstances, it behooves surgeons to comprehend the skills necessary for effective survival leadership.
Formal orientation of surgical teams to human error as it relates to the creation or perpetuation of an IORC, as well as the systematic role in mitigating the effects of those errors, is necessary for teams to be highly functional in all circumstances. Unfortunately, the lack of this formal training is exacerbated by a progressive reduction in resident operative experience combined with a self-reported decline in self-confidence.5-9 Because IORCs are rare, few health care professionals will have gained notable experience in crisis management during their career.2-4,10-12 In addition, anesthesia studies have revealed the following: past experience does not necessarily prevent failure; even senior surgeons make mistakes during IORCs; the signs of developing IORCs are often non-specific, resulting in a delay in the determination of the cause and appropriate corrective action; and during complex life-threatening crises, the team is required to rely upon cognitive tasking far beyond the information processing capacity of the human brain.10,13-14
Given that only an estimated 10 to 20 percent of the population has an ability to remain calm in the midst of a crisis, it is important to know how maladaptive responses to stress arise, how to develop coping mechanisms to overcome maladaptive behavior, and how to effectively lead a team through the risk-management process.15-16 Although past experience may not prevent a crisis from developing, understanding the concepts of human error, panic control, and team leadership, combined with repetitive realistic simulation training, should improve the outcome dramatically.
Other high-risk sectors, such as the U.S. military, law enforcement, the aviation industry, and even our anesthesia colleagues, are clearly ahead of surgery with respect to using simulation in disaster preparation. Immersion training, for example, currently in use in the U.S. military, allows for provider intervention in realistic intense environments. (See Photo 1.) Additional information on immersion training is highlighted later in this article. In spite of these innovations in simulation training, however, orientation to cognitive error, maladaptive responses, and rapid process decision making is actually limited in those fields as well.
This article provides information on the major strides that the military, emergency medical services, and other first responders have made in training personnel to lead in crisis situations and overcome maladaptive behavior that may exacerbate these situations. The myths regarding performance improvement techniques that are frequently embedded in the culture of high-risk professions—often to their detriment—are also explored in this article. And lastly, the authors describe a unique simulation training model that the military is using to prepare team members to respond to a crisis in the best possible way.
ORCM leadership training
Before they can effectively respond to crisis situations in the operating room (OR), trainees must understand basic concepts in crisis evolution and perpetuation, including maladaptive behavior, as well as effective leadership. The U.S. Department of Defense and the Department of Veterans Affairs health systems have used the following basic principles to educate residents and personnel in OR crisis management (ORCM):
Understand how IORCs evolve. On any given day, a seemingly minor error or spontaneous, out-of-the-blue event coupled with underlying systemic issues, poor coping mechanisms, subsequent mistakes, and faulty system safety nets may evolve into an IORC. This trajectory exists when the event is unexpected, potentially life-threatening, and requires time-critical, rapid decision making. Mitigating the consequences requires movement away from the current trajectory. Effective system design combined with preemptive team training should prevent propagation of an IORC to a disaster.17-20
Become familiar with time-critical, rapid-process decision-making strategies. It is important that trainees understand the decision-making processes surgeons use when they encounter time-critical events. Cohen and Pauley have described problem-recognition and problem-solving pathways in detail. Following an unexpected event, according to these researchers, people subconsciously detect that a change has occurred. At this juncture either maladaptive or adaptive trained responses will guide individuals either to failure or success, respectively. Adaptive individuals will comprehend all is not normal and begin developing risk-analysis scenarios in their mind to seek viable alternatives.17,21-22
Understand how maladaptive response, effective team command, and risk management affect outcomes. The goal at the onset of an IORC is to successfully manage maladaptive behavior and to organize, assess, and plan.
The road to successful navigation of a team through a crisis hinges on team recognition of the stages of crisis evolution and their ability to rapidly command the situation. To avoid confusion under stress, many responders use the easy mnemonic STOP—Stop! Think! Observe! and Plan!15,17, 23-25
The initial stage of this process centers on gaining control of maladaptive responses by stopping all activity. The fight or flight response, which most people experience in unexpected situations, typically leads to hesitation or panic. Trained medical team members should seek to minimize these maladaptive responses to stress and threats.17,26-27 Team members must be capable of rapidly accepting that the situation is no longer normal, and then adapt and begin an organized risk-assessment and planning-execution process.
Once these negative responses are under control, effective leadership, precise communication, risk-assessment, planning, and execution create a pathway to a successful outcome.17,20,28-29
A leader who will take command of the situation should be selected well in advance of a crisis to avoid potential confusion and anarchy. The leader’s first responsibility is to recognize and manage potential cognitive errors, including fixation errors, oversteering of the situation, and a loss of situational awareness.
Fixation errors occur when people fail to acknowledge a change in their environment and construct a familiar mental image based on past experience and fixate on it. Because they are unable to discount that impression, they cannot recognize what is really happening in the situation at hand and respond inappropriately.17,20
Oversteering can also complicate matters. This behavior commonly occurs when people attempt to solve a new problem with an excessive amount of normally acceptable actions. For example, when people find themselves lost, they frequently continue to wander and become more lost, instead of stopping to become oriented. Stress worsens this response.
Loss of situational awareness occurs when the team is overstressed, distracted, or trapped in confirmation biases and, as a result, lose touch with reality.17,30
Fatigue, environmental stressors, and distraction also increase the risk for errors. In multiple studies, surgical mistakes increased significantly with simple increases in flow disruptions, such as communication failures, equipment or technology problems, extraneous interruptions, and issues in resource accessibility.3,17,31-33
Just as the leader must be selected before a crisis develops, ground rules regarding team participation must be established in advance of a threat. Team participants must understand their individual roles during a crisis to avert further tension and confusion.
Basic communication processes also must be in place. Information passed to the team leader must be explicit, clear, concise, and focused.
Effective organizations practice and maintain orderly processes for risk-assessment, planning, and action. Principles that can be applied in developing these processes include defining the goal, gathering information, prognosticating potential scenarios, creating an action plan, executing the strategy, and reassessing the results.17,26
After any crisis, debriefing is critical. Team members should review the positive and negative aspects of care provided during the IORC and seek to answer three important questions: How did this happen? How did we respond? And what other solutions might have been used?17,34
Unfortunately, many institutions are still misinformed about the benefits of crisis training and the establishment of protocols to guide team behavior. Following are some of the myths that inhibit the use and adoption of these techniques, many of which are deeply ingrained in the surgical culture:
Team training and OR checklists have never been proven to provide substantial benefit. That’s what the “top guns” in aviation used to believe in the 1970s, but studies conducted by the aviation industry and the U.S. Coast Guard have shown otherwise. In fact, several decades later, aviation and military leaders have not only come to accept standardization of cockpit management training (CMT), but are at the forefront of implementing these procedures in their institutions. Surgical team leaders inevitably will have to accept the proven benefits of CMT to the patients and the surgical team.35 As the military has demonstrated, new technology will change surgical training, and acceptance of OR “cockpit” training will follow suit (see related story).
Training needs to be run and maintained by organizational leadership—not by the surgeons. Former American College of Surgeons (ACS) Executive Director Thomas R. Russell, MD, FACS, reminded us in 2006 that “ultimately, it is the surgeon who is responsible for ensuring that the entire operative team delivers safe care.”36 Salas noted in 2007 that although medical team training was in wide use, if physicians did not believe that teamwork was a critical element in the elimination of avoidable medical error, creating effective teams would be “an uphill battle.”37,39 The attending in charge sets the tone for the entire health care team, and therefore, must serve as the champion of IORC team training and its potential benefits.37 Changing a culture to one of continued vigilance requires cooperation throughout an institution, including administrative, medical, and support staff.
I am able to lead any team through any crisis without concern. During a post-incident evaluation, a pilot once stated, “We have to anticipate the worst case scenario. We are not just up there to press a button and trust in the wonders of modern technology. We have to be ready for this eventuality.”38 Until surgeons recognize that preparation for these rare, worst-case events is essential, continued mishaps and disastrous outcomes will occur. There is minimal evidence in the literature that the field of surgery has caught up to other high-risk fields with respect to crisis management. Overconfidence and a belief that these events are too rare to be of concern could have disastrous consequences when an IORC arises.2-4
We don’t let OR crises affect us. Adverse events create distraction and stress for the surgeon and team members. A 2008 survey of ACS Fellows showed that 8.9 percent of respondents committed a medical error within three months of completing the survey; lapses in judgment, fatigue, lack of concentration, and other distractions contributed to these mistakes; and medical errors and subsequent stress often led to burnout, alcoholism, and suicidal ideation. Errors inevitably increase stress and strain, create more distraction, and lead to more mishaps. Persistent stress and strain in an individual who is inadequately equipped to tolerate those forces does affect the OR team and institutions as a whole—often to the detriment of their functionality and reputation.39-41
The time has come for surgeons to set aside these myths and misconceptions so that the proper protocols are in place to handle any problem in the OR—no matter how big.
Effective ORCM training through simulation
More than a decade ago, it was discovered that collateral damage caused by military personnel and first responders was sometimes worse than the situation to which they were responding. This inability to respond appropriately and avoid further harm was a consequence of training that was frequently not life-like and therefore did not simulate the same epinephrine-surging environment encountered in a real-world event. Poor knowledge of cognitive errors led to mishaps attributed to individual ignorance or lack of adherence to known protocols. Soon thereafter the face of crisis training would change and evolve.42
To understand how to correct the problems with ORCM, surgeons must understand the basis of the mistakes just after such an event has occurred. Only recently have live, interactive immersion training, team training, and technical training advanced enough to be effective. Approximately 20 years ago, the groundbreaking work of U.S Navy consultant Bruce Siddle helped demonstrate that the immediate stress response to any crisis includes a loss of fine motor skills, amnesia, inability to listen effectively, and tunnel vision. He was able to correlate the immediate effect of the mistakes made during the immediate response phase to the eventual outcome of events.42
Based on Mr. Siddle’s findings, the U.S. Marine Corps developed immersion training rooted in the theory of stress inoculation. Stress inoculation involves training that puts the subject’s visual, auditory, olfactory, and tactile sensations in the actual environment and under real-world conditions. This training, now trademarked as Hyper-Realistic Training, has been developed by U.S. Marines and the U.S. Navy with the assistance of Strategic Operations, Inc., which is a part of Stu Segall Productions, a large independent television and movie studios. Now a mandatory course for medical personnel in both branches of the military, more than 1,000 health care practitioners—from corpsmen and women to surgeons—have participated in Hyper-Realistic Training.
This training system, developed over the last 10 years, now includes a unique simulation device to train health care professionals in team management and open surgical management. This instrument, known as the “cut suit,” allows trainees to develop skills needed for major hemorrhage control and to perform open laparotomy, open thoracotomy, cricothyroidotomy needle decompression, and closed thoracostomy (see Photos 2A–E). The suit is worn by a human actor, thereby accurately simulating the real-life stress involved in a major crisis.
This type of training had proven successful in operative management and training of the fleet surgical team led by U.S. Navy Commander Tuan Hoang, MD, FACS, both on ship and with a Marine ground force (see Photo 3).43 CDR Hoang’s crisis management team scenarios initiate in the emergency department and flow to and through the OR. Participants in these simulated events showed rising and sustained adaptation to stress.44
A second training scenario used the device to retrain U.S. ski team senior physicians (see Photos 4A-B), They “operated” in the cold with snow and 40-mile-an-hour winds on the actual Birds of Prey ski course in Vail, CO.45 Participants were surveyed before and after the course. Pre-training surveys revealed providers were alarmingly overconfident in their skill levels and underestimated the degree of anxiety they expected to face in similar emergent traumatic experiences. During post-training, participants acknowledged that they faced more anxiety than they originally anticipated, but also said they realized that in the simulation environment they could make mistakes that they could not afford to make in real-life scenarios.
This immersion concept has been integrated into a four-day training course for sophomore medical students at Rocky Vista University School of Medicine, Parker, CO. This course comprises scenario simulation for the emergency department and the OR. Scenarios involve various surgical illnesses requiring students to triage patient care and perform operative procedures. This training significantly reduces students’ stress levels and boosts their self-confidence and patient care management capabilities.43,46-47
Historically, simulation training involved stable scenarios. Although the environment itself may have been harsh (as in the Birds of Prey course described earlier in this article), the injured parties were known parameters. In these situations, it is rather difficult to portray an actual unexpected, threatening event requiring well-timed critical decision making. Recently, Vail Valley Medical Center, CO, under the direction of Barry Hamaker, MD, FACS, performed a simulated episode involving point-of-injury through the recovery room crisis management. This scenario involved a major disaster in the OR—during this training episode a critical care patient ended up in the OR with a visiting surgeon only known to the medical director and who happened to be in Vail when the disaster occurred. During the emergency laparotomy, a need arose to also open the chest, posing a crisis as the team was not set up for any of these emergent procedures. The OR staff had no prior knowledge that this event would happen. The simulated event evaluated team management and maladaptive behavior during an IORC.
Just the beginning
The simulated events described in this article are just the beginning for this type of immersion training in medicine. An actual 3-D simulated OR environment and software are being developed to record and replay every movement the surgeon and team makes. The growth in immersion training highlights the fact that intense military techniques are currently being integrated into civilian medical training and are not merely a distant thought.
It behooves surgeon leaders to move this issue toward the front burner. Although IORCs are rare, they are inevitable in any surgical facility, and failure to properly prepare the OR teams may have disastrous consequences for the patient, the surgeon, the team, and the institution. With current military training expertise available, it is up to surgeons to develop this training at all major U.S. medical centers. Ignoring the problem or anticipating these situations are manageable should they arise should no longer be acceptable alternatives.
Portions of this manuscript have been excerpted from Crisis Management Leadership in The Operating Room: Have You Prepared Your Team to Handle Any Crisis They Might Encounter In The OR, or Are They Destined to Fail? written by Kenneth A. Lipshy, co-author of this article.17
None of the opinions noted in this manuscript represent the formal opinions of the U.S. Military and are expressly those of the authors.
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