117. From Chaos to Control | Taming the tempest of task saturation

There’s no getting around the surges and potential chaos of an emergency department. The good news is that these events are predictable, you know they’re going to happen, just not when. So how do you prepare and then navigate the storm once you’re in the thick of it?

In today’s episode, we start with a discussion with Thom Mayer, MD exploring strategies to steel yourself for the inevitable chaos, underscoring the importance of maintaining a positive, agentic, proactive mindset. Drawing parallels to General Theodore Roosevelt Jr.’s decisive leadership on D-Day, the discussion highlights the critical need for quick, confident decision-making. A key focus is on the concept of “energy packets,” a methodical approach to managing the cognitive overload in the ED by strategically allocating mental resources to specific tasks. We also delve into understanding individual stress thresholds and how to manage stress without succumbing to a sense of helplessness. 

In the second half of the episode, Chris Hicks, MD gives his approach to managing high patient volumes, communication while managing critical patients, and how to address a direct challenge in the resus bay. 

Guest Bios:

Chris Hicks, MD

Chris is an emergency physician and trauma team leader at St. Michael’s Hospital in Toronto.  He has innovated in several areas of resuscitation and psychological skills, including mental practice, stress inoculation training.  These days he enjoys a quieter life, free from the problematic corporate jib-jab of academic deliverables.  In 2018, as a partial rebuke of the status quo, Chris co-created and chaired resusTO, an inter-professional simulation-based resuscitation conference in Toronto with international acclaim.  In 2020, he co-founded Advanced Performance Healthcare Design, consulting with hospitals and industry using simulation to inform the design of systems, spaces and teams.  Chris is an avid speaker and lecturer, staunch #FOAMed supporter, occasional runner and cyclist, fledgling boxer, semi-retired pianist, and proud father of three lunatic boys.

Thom Mayer, MD

Dr. Mayer is the Medical Director for the NFL Players Association, Clinical Professor of Emergency Medicine at George Washington University and a Senior Lecturing Fellow at Duke University. 

Dr. Mayer was named the ACEP Outstanding Speaker of the Year in the second year the award was given and has twice been named ACEP’s “Over-the-Top” award winner. 

On September 11, 2001 Dr. Mayer served as one of the Command Physicians at the Pentagon Rescue Operation, coordinating medical assets at the site.  Dr. Mayer has served on the Department of Defense on Defense Science Board Task Forces on Bioterrorism, Homeland Security and Consequences of Weapons of Mass Destruction. Dr. Mayer also serves as a Medical Director for the Studer Group.

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The Driveway Debrief

We Discuss:

Setting Yourself Up for Success at the Beginning of a Busy Shift

• Anticipate the chaotic nature of the shift with frequent interruptions and prepare mentally for it.
• Reflect on past experiences in the emergency department to better understand common issues and challenges.
• Your attitude is fully in your control, though it might not always feel that way.
• If you know that there’s a good chance of getting slammed when you walk in the door, how do you accommodate for that reality? It’s easy to complain or even collapse. Making a choice to set a positive tone and efficiently manage initial patient care will have compounding interest as the day goes on, both in your attitude about work and patient flow.
• General Theordore Roosevelt Jr. famously said, “We’ll start the war from here.”
• This was some badass full metal agency. A true stoic. Here’s the story..
• Roosevelt, then the Assistant Division Commander of the 4th Infantry Division, landed at Utah Beach on D-Day with his troops. Due to a navigational error, they found themselves about a mile off their intended landing point. Instead of retreating or trying to move to the original location, General Roosevelt reportedly made a quick and crucial decision. Understanding the urgency of the situation and the confusion that could arise from trying to redirect the troops under enemy fire, he famously declared, “We’ll start the war from right here!”
• This decision proved pivotal. His leadership and quick thinking helped to rally the troops, who then successfully began their push inland, playing a vital role in the eventual Allied victory in Normandy. Roosevelt’s actions on that day were seen as an example of exceptional leadership and decisiveness under pressure. 

Counting Down the Hours Til the Shift is Over

• It’s tempting to look at the clock when the shift is hard and, we we’ve all experienced, this can create a negative mindset.
• Engage in thought exercises or disciplined thinking to maintain a positive outlook, similar to focusing on the immediate path when mountain biking.
• Concentrate on one patient at a time, without getting distracted by the overall chaos.
• Organizing chaos in the emergency department requires discipline and a change in perspective about the specialty.
• The emergency department’s fast-paced and unpredictable nature as a challenge to be managed, not a problem to be solved.

Energy Packets – Closing the Loop on Open-Ended Attention Vampires

• The concept of “energy packets” in the context of managing mental distractions involves viewing your mental energy as a finite resource that is best utilized when allocated in focused, intentional “packets.” This approach is based on the understanding that our mental energy is limited and can be depleted by distractions and multitasking.
• The idea is to ‘close the loop’ on mental distractions by allocating these energy packets to specific tasks or thoughts, rather than letting your mind be pulled in multiple directions by distractions. This technique involves several key steps:
  • Awareness: Recognize when you are becoming mentally distracted. Awareness is the first step in regaining control over where your energy is directed.
  • Triage Your Tasks: Just as patients are triaged based on urgency, apply the same principle to tasks. Identify which tasks need immediate attention and which can wait.
    • Some will tackle the easiest first (bottom-up), others the more complex (top-down), and everything where you are the rate-limiting step.
  • Structured Focus Sessions: Even in a chaotic environment, try to allocate specific time frames to concentrate on one task or patient at a time. This might mean dedicating a few uninterrupted minutes to complete a procedure or documentation before moving on to the next task.
  • Minimize Multitasking: While multitasking is sometimes unavoidable in an ED, try to minimize it. Multitasking can lead to errors and increased mental fatigue. Focus on one task at a time wherever possible.
  • Scheduled Breaks: It’s crucial to take short, regular breaks to recharge, even in a busy environment. A few minutes away from the high-stress area can significantly refresh your mental state.
  • Delegate and Collaborate: Utilize the team effectively. Delegate tasks that others can handle, and don’t hesitate to ask for help when needed. Collaboration can distribute the mental load more evenly across the team.
  • Rapid Closure of Tasks: In a high-volume setting, try to bring tasks to closure as quickly as practical. This might mean completing documentation immediately after a patient encounter or rapidly deciding on a patient’s disposition.
  • Mindfulness and Stress Management Techniques: Quick mindfulness exercises, even just deep breathing for a minute, can help reset your mental state and refocus your energy.
  • Post-Shift Review: Reflect on your shift to identify what went well and what could be improved. This reflection can help you adjust how you allocate your mental energy in future shifts.

Identifying Your Stress Tolerance Level

• Acknowledge everyone has a limit where stress begins to negatively impact performance.
• Recognize that stress can be beneficial up to a point, enhancing performance.
• Identify personal stress tolerance levels to manage and control reactions effectively.
• Utilize techniques like brief meditation or reflective pauses to manage stress in high-pressure environments.
• Embrace the privilege of patient care, even in overwhelming situations, and focus on controlling personal reactions to chaotic circumstances.

When You Feel Like You’re a Victim and Losing Control

• Adopting a victim mentality can lead to decreased efficiency and a negative attitude.
• Focus on self-control and personal responsibility in challenging situations, rather than feeling overwhelmed by external factors. Where is your agency?
• Changing the system is a separate issue from managing personal responses to daily challenges in the emergency department.

Multitasking Makes You Stupid

• Multitasking is generally ineffective and can decrease the quality of work.
• The ability to multitask diminishes over time and is not a sustainable skill.
• Close energy packets to efficiently manage patient care.
• Prioritize seeing the whole playing field and making informed decisions rather than trying to do multiple things at once.
• The master skill in managing chaos is not multitasking, but strategic task management and prioritization.

Systems and Scribes to Mitigate Repeated Interruptions and Breaks in Task

• Scribes and evidence-based protocols can streamline tasks and reduce the frequency of task interruptions. Scribes can also make life more difficult if not used properly. This episode gives scribe efficiency tips
• Establish common approaches for handling frequent medical issues like abdominal pain to reduce decision-making time.
• Make critical decisions, like imaging protocols, in advance rather than in the heat of the moment.

Don’t Be Boring, Get to the Point, and Stay on a Level Playing Field

• Communicate effectively and succinctly with other healthcare professionals to ensure efficient patient care.
• Convey necessary information without unnecessary details.
• Maintain a level of mutual respect in professional interactions, ensuring equal footing in conversations.
• Strategically plan tasks to manage workload effectively, avoiding taking on too much at once.

Part 2. Chris Hicks and the Human Factors of Overwhelm

What Stresses Out the Teacher’s Teacher of Emergency Department Systems Excellence

• High Patient Volume: Hicks gets stressed by the overwhelming number of patients continuously arriving, creating a sense of losing control over the situation.
• How does he compensate for this?
  • Need for Internal Locus of Control: Recognizes that control over individual cases (like critical patients) is different from the uncontrollable aspect of patient volume.
  • Cognitive Reframing: Uses this technique to manage stress, especially during busy shifts, by focusing on achievable tasks rather than the overwhelming situation.
  • Basketball Analogy: Compares the situation to a basketball team in a losing position, emphasizing the need for focus on immediate, manageable goals to prevent disintegration under pressure.
  • Handling Volume: Admits that dealing with high patient volume remains a stressor, despite experience and strategies employed.

How to Keep Things from Falling Apart When You’re Slammed with Patients

• Identifying Immediate Tasks: In a busy shift, Hicks focuses on tasks that must be achieved in the short term, such as the next 15-20 minutes or the next hour.
• Pausing for Reassessment: Regularly pauses during the shift to reassess and prioritize the most critical tasks, without getting distracted by incoming patients or information.
• Balancing Attention: Manages the needs of new patients and those of existing patients undergoing treatment, ensuring both receive adequate care.
• Proactive Decision Making: Proactively handles tasks like complex procedures and admissions, and assesses new patients swiftly to prioritize their care.
• Dealing with Patient Streams: Recognizes the need to balance the care of patients already being worked up with those newly arriving at the department.

Putting Patients into Orbit

• Patient Orbits: Visualizes patient care as putting them into an ‘orbit’ where they are reassessed at the right time, avoiding too early or too late intervention.
• Timing Reassessments: Focuses on the optimal timing for patient reassessment, based on experience and the patient’s condition.
• Initial Assessment of New Patients: Prefers to quickly assess new patients, especially critical ones like chest pain or fever in a child, before delving into time-consuming procedures.
• Preemptive Actions: Before engaging in lengthy procedures or attending to traumas, performs necessary actions like ordering tests or assessing ECGs.
• Effective Use of Time: Manages time efficiently to ensure critical tasks are done, especially when other demanding situations like trauma cases are anticipated.

Taking a Pre-defined Pause to Review and Decide on Action

• Importance of Scheduled Pauses: Emphasizes taking pre-defined pauses to process information and make decisions, rather than continuously moving forward without reflection.
• Avoiding Information Overload: Recognizes that without pauses, one gets overwhelmed with piecemeal information, leading to inefficient decision-making.
• Decision Making in Context: Waits for all relevant data to return before making informed decisions about patient care.
• Team Collaboration in Pauses: Uses pauses to collaborate with the nursing team, ensuring all necessary actions are taken and no critical tasks are missed.
• Addressing Overlooked Issues: During pauses, identifies and rectifies overlooked tasks, like delayed CAT scans, to ensure comprehensive patient care.

Reframing the End of Shift When You’re Way Behind

• Realistic Goals for Shift End: Focuses on what can be reasonably achieved in the last hour of the shift for a safe and manageable handover to the next doctor.
• Avoiding Burnout: Acknowledges early career challenges with shift management and how reframing expectations helped in avoiding burnout.
• Work-Life Balance: Emphasizes the importance of balancing work responsibilities with the need to physically and mentally check out after a shift.
• Deliberate Task Selection: Chooses specific tasks and patient assessments to focus on towards the end of the shift, avoiding taking on too much.
• Cognitive Reframing Benefits: Finds that deliberately setting manageable work chunks when overwhelmed helps in actually accomplishing tasks, as opposed to being paralyzed by the workload.

Starting a Shift with a Ritual

• Pre-Shift Rituals: Engages in rituals like running or biking to work, arriving early to mentally and physically prepare for the shift.
• Importance of Preparatory Time: Values having time before a shift to center oneself, contrasting this with the disorientation of rushing into a shift.
• Assessing Team and Environment: Upon arrival, checks who is on the team and reviews the patient board to gauge the shift’s potential workload.
• Mental Preparation and Acceptance: Prepares mentally for the shift by accepting the potential workload and setting a positive mindset.
• Avoiding Negative Sign-Over Interactions: Stresses the importance of a positive and understanding attitude during shift handovers, avoiding judgmental perspectives.

The Mental Checklist When Walking into the Room of an Unknown Trauma Patient

• Mental Checklist for Frightening Scenarios: Mentally prepares for potentially frightening procedures like surgical airways or ED thoracotomies.
• Acknowledging Nervousness: Recognizes the importance of acknowledging internal fears and anxieties about unknown situations.
• Mental Rehearsal of Procedures: Mentally rehearses steps of critical procedures before encountering the patient.
• Preparation for All Possibilities: Prepares for any scenario that might unfold in the trauma room.
• Confidence in Handling Known Issues: Feels confident in handling known issues while preparing mentally for unexpected challenges.

The Three Things to Learn (or Teach) for Equanimity in a Crisis

• Mental Practice and Team Briefing: Advocates for mental rehearsal and discussing potential management strategies with the team.
• Tactical or Controlled Breathing: Emphasizes the importance of controlled breathing to manage stress levels and maintain focus during crises.
• Cognitive Reframing in Crisis: Focuses on breaking down processes into manageable steps, reinforcing positive self-talk, and setting achievable priorities with the team.
• Framing Priorities with Your Team
• Open Communication with the Team: Stresses the importance of discussing the situation and priorities openly with the team.
• Setting and Sharing Priorities: Establishes and shares a few immediate priorities to focus on, asking for team input to ensure nothing is overlooked.
• Using Visual Aids for Clarity: Utilizes tools like dry erase boards to visually outline and organize priorities.
• Managing Team’s Stress Response: Acknowledges the role of the leader in managing not only their own stress but also that of the team.
• Building a Shared Mental Model: Ensures the team is on the same page regarding the treatment plan, allowing for more efficient and coordinated care.

How to Effectively Answer a Challenge from a Team Member During Trauma Resuscitation

• Ego Management: Advises to keep personal ego in check and be open to suggestions from team members.
• Acknowledging Valid Points: Recognizes the importance of considering team members’ suggestions, even if they lead to a change in the treatment plan.
• Providing Explanations for Decisions: Believes in the importance of briefly explaining decision-making processes to the team, especially when a suggestion is not followed.
• Reevaluating Own Thought Process: Uses challenges as an opportunity to reassess one’s own thought process and decisions.
• Focus on Patient Care Over Ego: Emphasizes that decisions should always prioritize patient care over personal ego or pride.

Making Sure Decisions are Focused on Patient Care and Not Ego

• Decisiveness Balanced with Openness: Maintains a balance between being decisive and open to new information and perspectives.
• Data-Driven Decision Making: Prioritizes making decisions based on available data and patient care needs.
• Importance of Team Feedback: Values feedback from the team and considers it in the decision-making process.
• Acknowledging the Limitations of Perspective: Recognizes that one’s own perspective may not always be complete, and other team members may provide critical insights.
• Patient-Centric Approach: Ensures that all decisions and discussions are centered around patient care, rather than personal beliefs or ego.