Monday, June 6, 2016


          For the past year I have intermittently joined the HRO call established by Daved VanStralen, MD (see below) many years ago. The topics vary widely, but talks on Situational Awareness creep up frequently.  While I used to believe myself to be an expert in this area, I soon realized I had much to learn. Fortunately Dr. Jim Holbrook (Professor of EMS/Public Safety, Crafton Hills College EMS program since 1984) agreed to provide a basic knowledge base.
The question I ask many experts is "how does one maintain situational awareness, remain cognizant and on guard for potential errors and yet stay task oriented and not be overwhelmed.” Dr. Moulton and Greenberg warned me that people could become paralyzed in their indecisiveness if they are overwhelmed by an attempt to analyze all the sensory input around them while they worry about making a mistake. As I explained to Dr.  Holbrook, our world in surgery does not typically place a physical risk to the people caring for the patient. There is a mental risk if you fail in terms of humility or job security (litigation) but actual physical harm is not typically a risk during a crisis as seen in the military, police, fire service etc.

“Interesting problem you have.  How do you see above a paradox?
I have no experience in your environment and so my thoughts may not transfer.  The reason I mention environment is the groups you describe can be killed by their environment.  In these groups, the environment is always part of the assessment loop.  The training embeds both the environment and patient as dynamic.  There is no such thing as a static environment and just because the scene is safe doesn't mean it will stay that way.  So in EMS we teach zoom in - zoom out.  There are multiple ways to say the same thing (ex - hard focus / soft focus, marco / micro, trees / forest).  Basically we are getting the provider / practitioner to zoom in and complete a task or process and then zoom out to regain a larger view.  We also encourage this step when the provider is under the influence of a reptilian brain and other chemical processes.  We also add that if you're in your lower brain you need to exhale and start from the basics.  To demonstrate the technique to a beginning group I teach A-A-A-B-C with an assess - treat sequence at each step.   The first A is attitude, if you need an adjustment (+ or -) start there.  Once complete, move to the second step which is the atmosphere (+ or -) assess and treat.  Now to the airway-breathing and so on.  “

I feel that the art of situational awareness has changed drastically over the past several decades.
When performing open surgery, we did not have technology to take our focus off the patient and we could focus on the environment as well as the procedure fairly well in synchrony. Your intraoperative field of focus was an area about 6- 8 inches square. Distractions occurred but did not appear to be as significant as they seem to be in laparoscopic surgery.  Laparoscopic surgery has been shown to be more stressful on the surgeon and throws in a technology variable that needs to be accounted for. Thus in Laparoscopy your ability to focus on outside events or events even just an inch away from your field of focus, is reduced. Now instead of a 6-8 inch square you may have a field of focus that is only 2-3 inches in diameter (no longer a square). In Robotic surgery, one encounters an even greater distance from what is going on with the patient and the surrounding room because the surgeon is now tucked away in a console which diminishes hearing and totally out of view of what is happening in the room.
 In the trauma bay, several centers have a crew boss, whose job is to stand back and watch progress and not become engaged in routine processes in caring for the patient.

 It looks like you have a guy who can see the trees and not the forest and a guy who can see the forest and not the trees.  Hence the person whose sole function is inter-operator.  This person functions as the situation loop for the two different views.  This is a hard job in that they have to have situational awareness and high functioning communication competencies.  How this person cannot be distracted is important.
I would like to hear how you measured content within context and could you identify which domain of learning (cognitive, psychomotor, affective), your brain was watching from during the process.

ME: OK can you explain what you mean?

SA is the process of measuring content within context. The context is the environment and the emotions surrounding the individual events that are occurring. In the midst of this there is the affect or emotional awareness. Our brain takes in this sensory input and imbeds it into our awareness. This process varies depending on our profession.
My observation is that in general, Medical professionals are afraid of the non-technical world. Having said that the best clinicians I have seen are capable of quantifying AND qualifying things.
Affect is an extremely valuable but often overlooked variable in teaching.

ME: OK can you explain what you mean?

There are three domains of learning: cognitive, psychomotor, and affective.
Knowledge is the cognitive portion.
Skills are the psychomotor.
Affective is our emotions during this process.
For example, think about your favorite teacher and what made that person capable of teaching you successfully. Odds are it has nothing to do with their lectures or skill-teaching, but the way they showed interest in you and their response to your learning. It would be the chemistry between you and the teacher. Your response to that personality. That’s the difference between cognitive and affective teaching. Most focus is on psychomotor skills.
Or another example is to think about the question - what is the difference between stress and threat?
How a team responds to a threat all depends on their stress level.
This is where context comes in.
One surgeon can change the entire environment of the suite.
A coach can lead the team positively.
A negative person can increase the stress levels of the team.

ME: Ah HAH! So this then is the difference between transactional leadership and transformational leadership. Why transformational leadership works in the majority of circumstances. Even in the midst of a disaster, a leader who can bond with the team in one way or another will calm the team members down and their response will be positive. So how does one teach effectively then knowing this?

Use Affect! I do not think you can teach TALENT… you can provide structure during teaching but not talent. It is actually very difficult to transfer actual knowledge. You will be more successive if you teach from a cognitive state and then shift to an affective state. That is, ask “what did you feel in response to that”. In that case, you will attach an emotion to whatever you are attempting to learn. That feeling is now attached to a memory.

ME: So back to situational awareness and my original question: Can one be simultaneously situationally aware and not miss an important cue but not overwhelmed by sensory input?

JIM: In a stressful situation you attempt to map things out. You simply cannot keep track of everything. Let’s use a lifeguard on a beach for example. He cannot keep track of 1800 people on the beach. He must scan the beach for something that does not fit in. That is not easy if the problem situation actually DOES fit in; that is the problem is not unusual. Let’s say you know something is not right, but it just does not stick out. You mentally color your world in front of you while you are sweeping the area from right to left looking for what you feel you are missing.  You are asking yourself “what am I missing, that is so obvious that I am missing it”. You know you lost situational awareness and are attempting to reconcile your surroundings and gain it back.

So what is it that determines if we see the changes in front of us or ignore them?
Let’s say hypothetically my wife says “hey I painted the room and changed the curtains” and I did not even notice. How did I miss that? Then let’s say that she and I are walking at night and when I decide to cross the street all the sudden and she says “hey why are you crossing the street” and I say “to avoid that really strange looking person standing there in the driveway just staring at us”. How did she miss that and why do we respond to these cues differently?

JIM: “It is absolutely possible to 100% situational aware for a minute”, but not much longer. Your brain always sees these changes. You just choose to not pay attention to this and not that. It is the affective component that matters! So you miss something at home or at work. Your wife or boss then threatens you that if you fail to see a pattern the next time you are in big trouble. You will definitely see this the next time.

Well, I can honestly say this make perfect sense. It puts the information I have gathered from so many fields into context. I can understand more easily when those in other fields express concerns in their learning processes.


Daved van Stralen, M.D., F.A.A.P.- The Children’s Subacute Center, Community Hospital of San Bernardino, for HRO culture change in enhancing the lives of children dependent on long-term mechanical ventilation, Assistant Professor of Pediatrics in the Department of Pediatrics, Loma Linda University School of Medicine.

No comments:

Post a Comment