Saturday, August 19, 2023




On August 17, 2023. Dr Wayne Meredith*, graciously agreed to discuss the Wake Forest Baptist Health approach to establishing and maintaining Surgical Team effectiveness and resiliency, which they built over the past 15 years.

(video located at: )

Dr Meredith and I have had several prior conversations concerning team effectiveness, leadership, resiliency and surgeon ownership of the surgical safety process.

We first discussed this topic after he presented his work with NASCAR on team efficiency and communication some 10-15 years ago at the annual meeting of the Southeastern Surgical Congress.

Recently, we discussed the significant challenges most large institutions face with faculty development across vast expanses of practice with markedly increasing staff dispersion. Inevitably, institutions feel forced to rely on virtual synchronous and asynchronous learning.

On August 9, 2023, after Grand Rounds, we spent an hour in conversation focused on the Wake Forest philosophy for focusing on disparities in healthcare and on the need and the challenges in providing staff tools to respond effectively to microaggressions or outright biases and racism in the workplace. That transformed into a discussion about staff effectiveness, resiliency and a multitude of other topics including:

-Wake wings team training

- Critical incident debriefing

- Identifying and working with marginalized staff

- Second Victims-moral angst

- Team Resiliency

He was very gracious in revealing his process of addressing destructive team practices, including managing team decompensation, creating good habits and understanding bad habits to address situations that can undermine teamwork.

One other area Dr Meredith brought up was his leadership style in organizational change management and decision making, including effective leadership by deconstructing the situation and removing “sides” and finally avoiding organizational distrust by always publicly supporting higher level decisions.

Dr Meredith agreed to recap that conversation on video August 17, 2023.



Wayne, can you please recap our conversation last week about your critical event team discussions?

How do you manage teams that have witnessed a serious critical event and manage the team and individual mental health?

This concern has been identified by the American Society of anesthesia, American College of Surgeons, and countless other organizations as a significant cause of burnout and risk for future errors.


What we were discussing was the Wake Forest Operating Room Critical Incident Debriefing.

We have been using this venue to address individual or team concerns and distress for over a decade now. As a trauma surgeon we learned from EMS and the disaster management people, that one of the best techniques for maintaining team cohesion and building resilience in your teams to recognize when you've had a critical incident, and then to carry out a debrief on that issue. That debrief is designed to get those emotions dealt with at the time. It cannot be confused with Morbidity and Mortality conference or a Root Cause Analysis. At Wake, if anyone in the operating room, a surgeon, anesthesia, nursing staff, anybody requests a debriefing, it comes up through the well-versed channel. We find that many it's simply a matter of getting two people together then having them talk?

But sometimes something serious happens that is more global- such as unexpected death in the operating room or some serious team communication breakdown that results in disharmony or bad feelings. If that’s the case, we carry out a team critical incident debriefing. The Debrief is focused on preserving, maintaining, or creating team cohesion - it's pretty simple.

We pull the team together one morning at 6:30 before everything gets started.

We put the whole team together- all the circulators, all the scrub nurses, all the anesthesia people, all the surgeons and all the learners involved in the incident.

I usually have someone to research it - either the fellow or someone who was participating in the case just presented, that way we have some background to work with. At the debrief they go around the room starting with the person who has the least authority in the room. We start with a simple question for that person “when all that was going on, what were you feeling?” I have each of them describe what they felt. Then I make the observation- “OK, you've all told me what you saw, but none of you told me. What you felt.” I'll go back around the room one more time and at the end of that, typically I'll say “that was much better. But you told me what you thought, but you still haven't told me What you felt”.  Then people will start to get it and they'll start saying what’s on their mind. To assist, I'll give some examples such as were you feeling like you were not being listened to, or feeling like you didn't have power. Were you feeling like you're going to be fired. Did You feel like you're going to be blamed? Do you feel responsible?”

Then they go around that room and it's amazing how different everybody's feelings are.

It is almost universal from my experience in doing this that the people in the room have no idea what the surgeon is feeling or even thinking.

One of the spin-offs I've learned is when you're in one of those situations, you must communicate more about what you're thinking and what's going on right now because that can calm you and it needs to be handled then or it will spiral out of control.

I've learned that we think they're reading our mind and we're all on the same page but more often we are not. I've been working here 25 years and I've had two of these type incidents before, and they rankled me for years. It would have really helped me. I really think these are good.

Staff always come up and confer it's been pretty effective; it's been pretty useful and building theme that team unison. AND… it doesn't take much time if you don't do it for every single event.  You have to do it for the really major stuff, that’s worth the trouble for everybody.

Having said that I do prep the surgeons typically. I do a lot of espionage about the case from other people before it happens. When something like this happens, basically everybody knows and so more than one type of team member will bring it up.  I'll get the story from all these folks and ask what they think that issues are. We prepare those people ahead of time, especially anybody who hasn't ever been in one -that's new. We don't want people coming into this meeting with a sense of being threatened.

I let them know that we will do a root cause analysis of this in another area to create system catches for the areas where the Swiss cheese lined up for this case, but that we're not here for that- we're here to build team cohesion. We're here to communicate with one another. We're here to bond over a difficult situation and that that that gets them to it. It's pretty effective.



Wayne, it's obvious that your institution has adopted a real safety culture center around psychological safety, and I've talked to a few other surgical department chairs who have also managed to succeed in this.


I think this is a constant battle and I think it's way harder post-pandemic. We went through years without much social interaction, without face time with our colleagues and with people.

I think we lost ground during that time, and it takes space and time to rebuild it.

We never tried to do one of these with zoom, but I suspect it's doable, but I also suspect that it's too easy to retreat from the process and observe it and not participate in it by zoom, whereas in the room there's a feeling of, caring about what each other feels that I think might be hard to get on zoom.

We do that and everybody must go through Wake Wings. Wake Wings is a crew resource management to create hierarchy flattening and communication. Everybody does that fore they can come into the operating room. We refresh that twice a year with some of it using an outside speaker and internal grand rounds. We review rules that we've changed or the rule that we think we're having trouble with. We have some really good people running that.


Thanks Wayne! The Director of Anesthesia at Mercy Hospital (Dr Epperson) says that quarterly, they all meet for an hour or two of didactic and group discussions. Then they have breakout sessions where they go to an operating room where they have case based /simulations to discuss these things.

Is that something that's feasible in this institution? Can Wake Forest Baptist Health do that, given the size and the expanse of everybody in the health care system?  Or are you limited to having didactic discussions but not case-based scenario simulation?


We do that in this department.

We have 13 scenarios that Jeff Carter built in his research here. He was an educator prior to getting into his fellowship and during his research year, he did an amazing volume and quality of stuff.  He and Jim Johnson built a series of simulations of fire in the operating room, blood loss in the operating room, and others. We have a room designed for doing this adjacent to our operating room. I'll have to say that anesthesia started doing this as a part of the anesthesia safety national anesthesia safety program with mannequins 25 years ago. Surgery started doing it 10 or 15 years ago and we will go through those scenarios. We have other parts of the team observe it through one-way mirrors. Then we debrief using structured debrief. Martin Avery does that now for us. Sometimes we used cadavers brought in on an ambulance where the paramedics come in and we've done a whole scenario. I can say that since we started these simulations and Wake Wings, our communications have improved.  Our Med Mal costs, and wrong site surgery retained foreign body incidents have been reduced. There are a lot of tangible benefits from doing this!   The real cost is the time, and it requires a champion that wants to do it. You can't just assign it to people you know. It requires a champion that wants to do it and knows how to do it.

They are very worthwhile.


From my conversation with staff across the nation with the given difficulty we have to maintain a stable nursing workforce, in very large organizations, it is a challenge to assure that everyone in the OR has a shared mental model. How do y'all integrate the shifting nursing workforce in the operating room and into this training and into this safety culture so they feel free and mostly obligated to speak up when y'all have these critical incident debriefings? How do you know for sure that they're speaking their mind? Do they feel like part of the team? How do you do that?


Everybody takes the crew resource management – Wake Wings course. EVERYBODY! Even travelers- even sterile processing people. When we first began it, 15 years ago, we took 1400 people through this from February to July. In the end every single soul that worked in the operating room or came to it, took it. Then the time out is ingrained, and the daily process is performed the same every time. Regarding the timeouts – we are obviously constantly working on this, but those checklists serve as a great source of creating safety tools and investigating mishaps. You must keep your checklists trim, so they are doable. It’s a big deal for us to add something to it, but when we do it’s a consequence of a great deal of debate. We're not going to change to a bigger poster, or smaller print. We're going to figure out how to get this all done and this one little packet of time.

So, to answer your question, everybody who comes on does that, and then in the critical incident debriefing sessions, I've never had anyone that didn't begin to speak up. I have not seen anyone that never spoke, but remember we went through several rounds of it and the more senior people began to open up. Also remember I prep the senior people to assure there is no barrier to free thinking.


One other common concern surgeons and anesthesia express is that one of the biggest issues is that in any case that lasts longer than an hour, you have multiple staff changes, including anesthesia and nursing changes within the staff. These are staff that do not originally participate in the initial timeout. How do you assure that that shared mental model that was created at the beginning of the case? If we introduce ourselves to the staff at the beginning and then we have staff that replaces that staff, how do we engrain them into the team immediately and effectively?

How do we ensure they don't come in feeling lost and uncertain and not sharing the same mental model that probably the initial team did? That way at the end of the case, everybody can speak the same language, and everybody understands what happened and communicate when these problems exist, right? To make sure that this gets communicated, that this was a particularly challenging case, and we really need to assure that a critical incident debriefing is done.

That's a problem, and it's one where people talk about how effective crew resource management training is in the airline industry. I always have the thought that everybody that forms the team when the plane takes off stays on it till it lands, right? Over the years we've created a whiteboard structure in the room. That has everybody's name and role on it and a few other key pieces of information. There's a there's a very short handoff that's done, whether it's circulated or circulator or scrub to scrub. It goes on in the back of the room. I was saying it has incomplete penetrance but our process rules are that you ask before you change. You can't start changing the circuit. It's sometime during the case when you can afford to have that break in concentration from your teammate and they always know that they don't always ask, but they often do and usually do, I guess. Obviously, all the counting goes on as part of the handoff, right? And they gotta redo the counts. That’s partly why it's important to put that in in a time in the operation, when it's OK to do that, right. We do that through the White Board, which has had several evolutions of data that's on it. Based on instances we've had where the holes in the Swiss cheese lined up that we had a communication break now and we've added it, added different things to the to the White Board.



In 2016, the American College of Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS) hosted the first National Surgical Patient Safety Summit (NSPSS) Program. The mission of the program was to "propose solutions that effectively combine elements of safety science, principles of high reliability and best safety practices across all phases of surgical care." (Summary located at: ). The topic frequently turned towards our constant shift in medicine to create aviation crew H.R.O. models to improve patient safety. 

After that, in 2017, LD Britt and I discussed some of the concepts that came out of this meeting.

I asked him how do we deal with the public pressure regarding the concerns that aviation has reduced fatal incidents and near misses using crew resource management but medicine had not yet seen those same results almost two decades later. Is it unrealistic to have an assumption that simple checklists and CRM training will work due to the fact that health care is substantially more complicated. Dr. Britt did not hesitate, and said we have to start somewhere and that place is to work with the CRM concepts and not focus on the differences between aviation and medicine as a reason not to improve, but as a reason to excel.

In 2015, I spoke with several members of the 2015 South Carolina Surgical Safety program regarding the inconsistency of full completion of their goals. I even contacted members of the South Carolina Hospital Executive Group to discuss this with me. Universally they revealed that failures were due to this being a surgeon driven process in sites who succeeded and an executive driven process where if failed. You have to have a surgeon and or nurse manager and other anesthesiologists. They have to band together and say enough is enough.


This is really a model that takes surgery, anesthesia and nursing to form this bond and make it happen. With other hospitals in our system approach us and saying we would like to start a Wake Wings program. The first thing we do is go find out if there's going to be sufficient surgeon champions and anesthesia champions to pull it off, and if they're not there, we don't do it and we help them fine. There would be there would be champions and then we coach those people on it and then we then they start becoming train the trainers, they take the course so then they or they take and then they take the instructor course and we spread it. But we, won't do it without champions.
We had external consultants of that, that came from life wings in Nashville. They spent several days with us. First with five critical people and then 15 critical people. Then we worked for two days with 45 or 50 thought leaders in the operating room going through the course, taking it and then going through the design process, starting with building a common mental model of what wake wings was going to be.
That still started with a little bit of a Big Bang, right?
We had lots of champions who knew understood the plan. There wasn't just one, just me or one other one person, one around selling it to 1400 people, right. We had 50 or 60 champions.
Many of them alternated and became instructors and were former first wake wing steering committee members.

It's still a lot of work to keep it maintained.

Ken, you keep saying this “culture where you have built” but I how would admonish you to think of this in terms of this culture you are trying to build. This culture you are working on. Because I don't think this is not a one and done.  I know we're not there we're not where we need to be. Where I would like to see us be but we're putting one foot in front of the other all the time and trying to work on it yeah.  


Some large institutions note that the process of having annual team training unfortunately does not produce enduring results. They recommend ongoing training.  But several consider ongoing, to mean asynchronous learning modules. I believe we know that asynchronous, 1:1 computer modules do not have lasting results and that face-to-face case-based scenario/simulation models work in the long run.


We have not figured out how to do that here at scale. we can have segments of it where we take a time that we are already have set aside for learning. Our department and orthopedics and urology have this their educational modules but it’s hard to get a multidisciplinary team free all at one time and in one place.

But having said that, those residents graduate and carry that skill with them.
My mentors used to say you're just one generation away from the Stone Age all the time.

Everybody, on Earth forgot all that. We knew we'd be back in the Stone Age immediately if this was not continuous. That's a challenge, it's going to turn out, for us to do everybody they worked in the operating room at one time. It costs us some money in terms of trainers and people that we paid to do it, but the time of people that will were there came to work that day and their job that day was to go to weaklings training for half a day was hundreds and hundreds of thousands of dollars for that one day for us to do it right.

For me, that's a big thing, for us to do.

On the other hand, I think there's a lot of payback on the other end of it.


Well, you know that's I think your institution has recognized and you already said this once that the payback is, you know, not necessarily in terms of dollars, but you know the prevention of a patient safety incident, the ability of y'all to have a shared mental model.



Wayne, when you become aware of a highly emotionally triggering event, does Wake Forest Have a process to help individuals process and heal?

General Surgery News recently posted a testimonial of a Surgeon who endured a tragic death of one of his patients, and his story concluded that he was left to his own accord for counseling and help. He recounted that when they published his first account, many surgeons contacted him to thank him for his honesty as the vast majority of surgeons feel as though they are on an island when such events happen. In fact, a recent LinkedIn editorial comments that many physicians constantly feel all alone.

It was the same time Balch and a couple of others wrote a paper for the college about burnout and subsequent risk for suicide, alcoholism and other things. Prior to that the ASA published a study that revealed that it rare that someone in anesthesia was given time off after witnessing an enormous critical event death on the table or something similar. Severe, irreversible neurological deficit due to something that happened and it was it was it.

I interviewed several law enforcement officers asking how does their department handle that situation and they told me that have people that will respond on the scene and talk to someone and they'll talk to the people involved and decide if they're equipped to come back to work or if they need to be reevaluated before they return to duty.

You want to be sure that when something wrong does happen, you're not losing staff in the midst of this, and staff who are distracted by something that occurred that they have no way to resolve it internally, they will eventually create another mistake that leads into my last question for you.


It was eye opening to me when I realized the number of staff who are involved in that incident, who had to go to work on that case, right and you know, and just the thought that in medicine we don't really have a process and most scenarios to find a way to alleviate that person who now has been traumatized to that team.


Do you have a team that comes in and works with them to get them fit for duty?


We send them some to pay anonymous place.

Individually to work through that, and then they have to be signed off on to be fit for duty.

If they're still bothered by and it's way more than just a case, an operating room, workplace violence- someone that's beaten up in the office or the holding room.

It is surprising how many of those people years ago were affected. How seriously and what they need?

How much additional support they needed from the institution to get back to good to go again?

It's really you can't just seal team six your way through some of those tough things.

They're hard to do and I think that's actually true for us as surgeons as well.

We need to be mindful of when we have been put through the wringer of a case that you feel guilty about. Get it off your chest and wait.

M&M is not the answer for that, even if you confess your sins at M&M's that's not the answer You need to go through a process of describing what you're feeling more than and sorting out how to get back to resilient.

I do think it's an important skill.

For trauma surgeons in particular.

But everybody will have one, right?

I think it's very important to develop the skill set to that, elite athletes do.

If you watch some of these documentaries or talk to some of those people there, there's an ability to put aside the bad play right now and finish the game.

And then after the game… Confer with your friends and partners teammates and go over it and hate it. Feel lost from it. Feel remorse about it, then stop feeling that way.

Learn from it and go out and start getting ready for the next game.

And it's a great lesson performing athletes have to have that ability, or eventually they all gets in their head and it messes them up and they can't.

They can't do the game right and so and I've listened to lots of those.

I've read lots of books about uh people talking to.

Talking to the G.O.A.T.s is great book and he and he talks to, you know, Tom Brady, and he talks about his time with Muhammad Ali and the goats.

They all take responsibility maybe more than they should but they all take responsibility and they all go through this process of internalizing it, grieving at learning from it and then ending it and then being done with it.

that's a hard-fought skill set to learn.
And I think it takes help, right?
I mean, those guys have learned that since there were playing pop Warner, right?
They have been trying to practice dealing with loss.

They're dealing with loss that you're responsible for or dealing with injury.

Has truly elite people have been practicing the mental discipline of doing that and they have.

They have mental discipline coaches on their teams, right?

They have physical coaches on their teams and they have mental discipline coaches on their teams look at a golf pro.

If they can afford it t, that and some of them are just more psychologists, we don't.

We don't do enough that I have seen some mentoring programs written about where senior surgeons go into the operating room with another senior surgeons and they just observed them and then they tell them .. here's some tricks that I observe from watching you.

Not blaming not anything like that, but just having an external eye.

Observe what you're doing and then go over it is.

Yeah, and I get called in a lot to help other surgeons and we will almost and I will push very hard to debrief those cases with the learners and without the learners.

And I've tried to debrief on the pieces that they saw in what I was doing.

What did you learn from what I was doing and what did you learn not to do?

Well Wayne we have covered 45 minutes about a very broad range of topics

Dr. Meredith is the Richard T. Myers Professor and Chair of the Department of Surgery, Chief of Clinical Chairs and Chief of Surgery at Wake Forest Baptist Health. He graduated from Wake Forest School of Medicine in 1978. Amongst his many surgical society leadership roles, he recently served as the President American College of Surgeons from 2020 to 2021.

Kenneth A. Lipshy, MD is ACOS Surgery Salisbury VA Healthcare System (Charlotte, Salisbury, Kernersville).  Associate Professor Surgery Wake Forest University.

(Welcome to Crisis Management Leadership).


The content of this editorial represents the opinions of the authors and correspondents noted herein and does not represent the opinion of the United States Federal Government or Department of Veterans Affairs or Veterans Health Administration










CRISIS MANAGEMENT LEADERSHIP: Training to Survive the Critical Moment © Sept 2021


One major hurdle for patient safety initiative implementation has been lack of staff buy-in. Staff frequently are hindered by 'checkbox fatigue'. As a result, staff simply may go through the motions.  However, as Berg’s meta-analysis of surgical safety checklist studies concluded, implementation of checklists is more than checking off boxes.

In a review of the implementation of the World Health Organization (WHO) Checklist in the U.K., Russ and colleagues concluded successful implementation of the WHO Checklist required the following: Modification to suit the local context to ensure integration into existing programs and enhance buy-in. Education tailored to the needs of each stakeholder.  Identification of local champions to promote safety in clinical work areas. Executive leadership support. A system of accountability for “improper” behavior or noncompliance. Careful auditing.

STAFF BUY IN-Staff Buy-in is absolutely essential. Richard Karl, MD, FACS, a commercial pilot for JetSuite Irvine CA and Chairman Emeritus, Department of Surgery, University of South Florida, Tampa, stated that though medicine is far more complicated than aviation, many tools

 associated with improved air travel safety could be used for error reduction and improved outcomes in health care if implemented properly.  However, "you can't just slide a checklist under the operating room door and expect it to work," he said (personal communication July 2016).

RETHINKING TEAM CONCEPTS: Douglas Paull, MD, MS, [director,Patient Safety Curriculum and Medical Simulation National Center for Patient Safety (NCPS)] suggested (personal communication July 2016) that considering the dynamic state in which medical teams function, health care organization should introduce the Amy Edmondson's concept of the action of ”teaming.”  (Edmondson).  According to Edmondson, health care are not static groups. The members have different levels of training and competence. Furthermore, team composition is dynamic, with different members performing different responsibilities in the course of care or of a procedure.  Moreover, several leadership units are often at play in an OR, including nursing, anesthesia, and surgery.  Team training in health care, therefore, needs to account for the dynamic interactions between units or special teams. (Edmondson). As surgeons, we ultimately have responsibility for our patients’ outcome and experience. We set the tone for a safety culture.

WHO IS LEADING THE WAY? In addition to communication failures, a lack of leadership is a key driver of sentinel and adverse events. As Dr. Paull said, "Leaders set the tone for safety culture...leaders by their words and actions develop an environment that rewards people for speaking up with safety concerns."  While the captain-of-the-ship model in medicine may no longer be applicable, physicians must take the helm and steer this patient safety process. Leadership is vital to ensuring the team remains focused and on target.

The concept of "oversight of the entire process" would suggest that surgeons should be invested in the entire patient safety venture. However, surgeons frequently become disinterested in an educational program as soon as they hear it is non-technical in nature.

 In 2015, Russ and colleagues noted: that “the  most common barrier to checklist implementation, reported by 51% of the sample was active resistance or passive non-compliance from individuals on the OR team, most frequently (84%) from senior surgeons and/or anesthesiologists. This often made it challenging  for the person leading the checks (often a nurse) to complete them in the intended manner, or without feeling personally attacked.”

 Often only after something untoward occurs, do surgeons take interest.

(RUSS) Edmondson recently noted that in a prior study on the development of minimally invasive cardiac surgery (MICS) programs, the key to success hinged on how the lead surgeon viewed their stance as a member of the team. In the instances where the lead surgeon viewed themselves as part of a partnership aimed at the benefit of their team and patients, the project succeeded. These surgeons tore down the silos and ensured everyone had an equal role in the success and failure of the project. However, when the lead surgeon practiced authoritarian (top-down) leadership and simply expected everyone to execute their job as directed, the project failed. (Edmundson)


One final area of contention is the continued use in the scientific community of James Reason’s "Swiss Cheese Model" as a model for healthcare HRO’s.

 (REASON) However, this model, which suggests that that there are stepwise processes where errors occur and are easily detected, may be too simplistic for use in health care. In complex systems such as medicine multiple cogs move simultaneously. The process that we believe we have put into check may change the second we move onto the next task.  (Cook and Rasmusen)


Balch et al. related that burnout and other measures of surgeon distress correlate directly with increasing work hours over eighty hours a week and nights on call over twice a week among American surgeons. They noted that “when physicians are in distress, their performance in delivering care can be suboptimal” which increases risk for a home-work conflict and lapse in judgment. In patient care (and especially surgery) there is always the expectation of a quick success. As Bosk reminds us in “Forgive and Remember: Managing medical Failure” the first question asked after any failure is, “what did you do wrong?” On top of that, unfortunately, most of us harbor maladaptive behavior in times of failure or significant change.

A recent American College of Surgeons survey on burnout revealed a tight relationship between causing a patient error and stress, fatigue, burnout, alcoholism, and suicidal ideation. In this survey, 8.9% reported committing a medical error within the preceding three months. The majority of these contributed this to a lapse in judgment, fatigue, lack of concentration, and other distractions. Further assessment of the responders noted that a prior medical error was independently predictive of high alcohol use and suicide ideations.

Similar findings are noted above from a recent ASA study on the effects of negative outcomes in the operating room on anesthesia providers.3

Bernstein’s group at the University of Toronto conducted a survey in 2015 assessing the mechanisms whereby residents learn to recover from a traumatic impact during their residency. The study confirms that residents are still distraught over the lack of formal mechanisms around to assist them in that recovery process. That is, the idea of helping the second victim, does not appear to be universal.  (Balogun et al). Thus, anything that reduces errors reduces distractions from the team and creates a safer environment for patients and staff.


84% experienced more than 1 unanticipated death or serious injury over career.

70% experienced guilt, anxiety, and reliving of the event (88% requiring time to recover emotionally & 19% never fully recovered, 12% considered a career change).

67% believed that their ability to provide patient care was compromised in the first 4 hours subsequent to the event.

Only 7% were given time off.

CONCLUSION: A perioperative catastrophe may have a profound and lasting emotional impact on the anesthesiologist involved and may affect his or her ability to provide patient care in the aftermath of such events.


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