Tuesday, May 10, 2016



        A few months back, a couple of papers were published assessing resident response to catastrophes and how surgeons go through the process of "risk taking" behavior based on positive or negative experiences during their career. I was fortunate to talk with Dr. Moulton about their paper on risk taking but still attempting to reach Dr. Bernstein on their paper on how residents feel about their training to respond to catastrophes. My conclusion, was that we continue to do a disservice to our trainees by not providing them with sufficient skills to process an untoward event so that it won't overshadow their positive experiences thereby reducing their willingness to tackle difficult problems. Instead we teach quite the opposite. 'Suck up and don't talk about it' seems to be the going mantra we portray to them and our colleagues. And no, it's not just a surgeon trait. As in my prior post on this subject, an ASA study showed virtually all anesthesia providers continued to work after a loss of life in the OR. The ACS survey series in 2010, showed a direct relationship between making a mistake and subsequent burnout. We do have a long way to go.

        On that note, Daniel Linskey was gracious to talk to me about his role and response during the Boston Marathon Bombing April 15 2013. He is the former Chief of Police Boston, a retired Marine and the Incident Commander during the Boston Marathon Bombing so I believe that anyone who has to learn to function during a catastrophe should listen closely to what he had to say. This completely resonated with my ongoing "research" in how we address crises in surgery. I sincerely appreciate his honesty on what happened and how he responded.

      I will just cut to the chase on his advice and go from there: "Realize you WILL be overwhelmed… learn how to control yourself quickly, take in cues, so you can open your file cabinet and then control the team." He said that you have to understand that under extreme duress the amygdala response will "hijack you". This conversation brought to mind the 2014 commencement speech by Admiral William H. McRaven to University of Texas Austin graduates (Retired ninth commander of U.S. Special Operations Command* and Chancellor at The University of Texas). “Every SEAL knows that under the keel, at the darkest moment of the mission– is the time when you must be calm, composed—when all your tactical skills, your physical power and all your inner strength must be brought to bear. If you want to change the world, you must be your very best in the darkest moment.” Police Chief Linskey's conversation reminded me that it takes an abundance of training to achieve that degree of resilience. Very few humans can withstand that degree of pressure and maintain focus without significant training. Even then, you just do not know what your response will be.

      Chief Linskey noted that on the day of bombing in 2013, they felt prepared but alert. By this point he had already successfully led several full action city-wide disaster rehearsals -known as the "Boston Urban Shield". Turns out though nothing prepared him for what he was about to face. He was a boots-on-ground Chief so he was out there in the field. He began his routine by making his way in front of the Forum. However, his pattern of surveillance was thrown off by a seemingly innocent conversation. An officer on the beat stopped him to chat about how he moved five houses from the Chief’s house. That twenty-minute conversation may have thrown his routine off. As he made his way down the street he had a nagging feeling that he had missed something during the distraction. Later, that office was injured when the second blast occurred.




       He was a mile down the street when the first bomb went off, but immediately jumped into his patrol car and drove back to the forum.  He recalls that the scene was overwhelming as he spotted an eight year-old child ripped in half right at the spot he had earlier been conversing with the other officer. He then realized he was totally thrown off by that conversation. It hit him “the uneasiness I felt was that there were backpacks around and I should have had the team evaluate the security of those! I just got distracted”. As he tried to stop the child's exsanguination, all he could think of was that he missed the backpack. He felt that he was responsible for that boy's death. “I had extreme guilt and doubts until I saw the video Wednesday morning showing I didn't miss it. It was only there for 6 minutes.” The guilt was just a part of the scene that began to overwhelm him as he quickly became overloaded. He recalled “I kept thinking -here is the top Police officer and I had no control'. He felt himself hyperventilating, shaking and getting even more out of control. His instinct took over as he began to respond directly to those in need. He was able to start the process to control his fight or flight response “I began to think more clearly”. Instead of becoming the strategic leader, he began to help the first responders tend to the victims. He realized on later reflection that “it was easier to not be the leader in this situation. Subconsciously I felt overwhelmed and was hoping someone else would take charge”.      

     After what seemed like an eternity, a State Trooper, who he knew well, grabbed him and began to yell at him - “Chief! We need you out there in the street”. The Chief's first response was to cuss out the Trooper- Chief Linskey told me, I wasn't pissed at Mark for putting his hand on me I was pissed at myself that he had to remind me to be the boss.  The Trooper said ‘Chief I’m just trying to…’  I cut him off ‘Mark I know what you’re trying to do, just give me a F….g minute.”    Chief Linskey understood that the trooper sensed that the Chief had taken the responsibility of the injuries personally and was not able to process the scene in a productive manner. The Trooper relayed that he also knew that deep in the Chief's brain was the trained instinct to control the scene and lead the response, so he was simply trying to find the commander in there. The Chief had always had the reputation as the calm one in the midst of adversity so somewhere deep under that cussing yelling ball of fire was a true leader and he just needed to get that man out. It worked! That triggered his innate leadership and police skills. “I took the deepest cleansing breath sighed and began to run the scene

      The Chief described a wave of realization that hit him at that moment. He became extremely calm and began to know exactly what he was going to say before he said it.  He knew he had a head packed with a vast library of experience and training and that opened before him- everything was clear- 'what to do and what not to do'. The cognitive processes which Gary Klein and I recently discussed slowly unraveled in his mind. The Chief's brain went thru the motions: #1. Understand that a problem exists 'CHECK! we have a problem!' #2 determine what the problem is-"This is a crime Scene". #3 Analyze the problem-think! "what do you do in a crime scene?". #4 Brief the team, get information (see below about information pitfalls) and Get a plan out to the responders- start your process you trained to do- “this is a crime scene, you need to investigate and control” "give people jobs to do so they will assume their roles, feel they are taking some control and establish order".

         Things quickly took a turn for the better. He quickly reestablished some sense of order amongst the chaos. As the rehearsed sequence of steps came back to him he calmly provided instructions:

a. 'we need to prepare for secondary incendiaries'

b. 'we Need bomb squad to look for other backpacks'

c. 'We need to look for the perpetrators of the crime'

d. 'we need to sweep the streets for suspects and clear them of bystanders before more people get injured'.

e. 'We need to hold the bars and restaurants to keep people off the streets until everything is clear'. 

f. 'Need social media to inform folks what was going on so people can report suspicious behavior'.

g. 'We need to think now about what to do ahead.' Chief Linskey says that this process felt like it took place over a very long time period, but on review, in real time it occurred much quicker.

In the end of our conversation he passed on several valuable lessons:

1. No matter how much you prepare, you can never be ready for a terrible catastrophe- Even with simulation/rehearsal, people will need reminders what to do when they are scared. So we need to make our simulation as real as it can get and provide trainees with the skills to be resilient and survivors.

2. No matter how much training you have under your belt, you will always have self-doubt. At the moment the crisis hits it does not matter if you are confident in your ability to lead or not. What matters is how you can convince your team you are in control. You must Project calmness! You may have guilt from your personal direct or indirect actions or inactions….. GET OVER IT. PEOPLE are relying on you. YOU may have a personal injury or witness someone you know well or love injured…. The team needs you right then, so while it sounds easy to say, you need to lead if you are the leader.

3. Don't overload people- Always keep priorities to less than five goals or people will have too much information to manage and it will only complicate matters.

4. "Information" management - Be extremely cautious about information you receive surrounding the incident. That is, your initial response may be to accept the information or to reject it. You probably just want to believe the information, since you have limited time but likely either sparse resources of information or too much information. Your reaction may be to just accept it for fear if you don't you could be liable - you feel you will be held responsible for not reacting on that information and if things take a turn for the worse, then you will look bad. In addition, you just don't have the time or energy in your mind to analyze everything. Therefore, you need to train yourself and your team how to manage information. That is, you must rapidly decide what information means- as in, will this exacerbate the problem or improve things? You need to find out immediately Who provided it, what was said, when in the series of events did that information come about (is it now too old to be of benefit) and how was this information gained?

5. In a crisis we need solutions not a procedure- in a crisis if we rely on procedures and worry about violations instead of what we really need to do, then there could be disastrous delays. Too much information can be deadly.

6. Under duress people will act differently than they did during rehearsals and briefings so you better learn before a crisis about what people will do, or things can end up disastrous. One example was that in spite of prior discussions about using tourniquets, people were very leery about them. They learned what would go wrong with tourniquets and frankly were typically told to never use them before. In many cases people would look at the tourniquets but not tie together the mental response that in their hands they had life-saving equipment so they failed to actually use them.

7. Finally when you have a moment, you must decompress your emotional load as soon as possible- As a leader, you have to know when and how to dump your emotional battery and recharge. It may be that in the midst of the battle when you have a chance to breathe, you steal a spare second to scream to the air or cry. When the dust settles, you must assure all involve, including yourself, are provided counseling. In police actions, in response to tragedy, teams are trained in critical incident crisis psychological management and those teams come in immediately. The people in the field have immediate access to Trained staff that work with them there and over time to help them debrief and work for future problems. This is extremely rare in medicine.

Needless to say I am very humbled by this conversation and extremely gracious for Chief Linskey taking time to talk with me. THANKS CHIEF!


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