What I did: Pediatric Intensive Care Unit (PICU) 1989-1995

A few years after we had created the PICU I noticed that the pediatric residents had returned to their higher performing level after day 11. (This was odd, as it was consistently day 11 regardless of the day of the week or when our coverage as attendings. Dr. Perkin noticed it to; it was not day 10 or day 12, but on day 11 the residents picked up on things earlier, responded more effectively, their stress and anxiety dropped, and they came together as a team. On day 11.) The residents have a one-month rotation beginning on the first day of the month with two-to-three months in the PICU during their last two years of residency training.



Ron Perkin would teach:

Support the bedside caregiver even when they are wrong. There are ways to do this without making people the wrong this was fine to do.

Never criticize anyone. They had a good reason for their action or a justification for their ideas. We can learn from them.

When someone gives an explanation with cogent reasoning, we must find a way to make it work, or at least to make sense of it, even when the reasoning is wrong. This can be circuitous but we must remember it made sense to the person for a reason.

Use simple principles to explain the situation and to guide interventions. In complex situations or under time pressure we can process our thoughts more effectively if we use simple principles.

Develop five or six causes of what you saw and five or six ways to treat it. The first one is the easiest to think of, not necessarily the correct one.

Always say yes, volunteer to help. Often, no one else would come forward to help. Because of the broad nature of our work and the diverse groups we work with we could often assist in unique or unexpected ways. If we did have to withdraw, people are less inclined to criticize you if you have a reputation and practice for helping and volunteering.

I gave four lectures:

Monday was organizing complexity.

Tuesday was unrecognized stress and fear.

Wednesday we discussed decision-making.

Thursday morning we watched Weird Al Yankovic music videos.

Organizing complexity: The first day I came on service in the PICU we would usually have a patient on a ventilator with multiple medication infusions and a large number of problems. The child may have several diagnoses. The usual format of presenting a patient is the most serious problem first but typically the residents would present the problem list with the first item being one they knew about and used routinely, which was fluids, electrolytes, and nutrition (“FEN” in their words).

We would first list all the problems coming up with about 20-30 items. I would then group them as common causes or diseases. Invariably we would have 3-5 major issues to deal with. One would be life-threatening (for example, septic shock), one would keep the child in the intensive care unit (for example, being on a mechanical ventilator to support lung function), and the other two or three would resolve over time with straightforward treatments (for example, infection or wound healing). From over 20 things they needed to monitor and respond to we now had basically one and if we could address that one the child would more likely survive and the rest will follow. It became easier now to develop strategies for treatment and they would spend less time on the minor but easier issues and more on the critical matters

Unrecognized stress and fear: I used Ray Novaco’s model of stress that he adapted from Lazarus. We would list the demands and expectations placed upon his in an review our attributes (what we have as individuals) and resources (what others, particularly our organization, can help us with). If demands and expectations exceeded our activism resources we needed to reevaluate. If we do not reevaluate we stay in an increased state of arousal that, if unidentified within ourselves, would lead to a stress reaction. This is a matter of self-awareness.

We also discussed unrecognized fear in those around us that was usually manifested as anger (fight), avoidance (flight), or freeze (the freeze response of prey species). We also discussed maneuvers for ourselves and when interacting with others having these responses.

Surprisingly, this was a rather popular lecture and there were times when a senior resident would ask me to repeat it for the junior residents or an individual would pull me aside and ask for a repeat presentation.

Decision-making: This had several parts. I taught decision making based on John Boyd's OODA Loop that I learned from Lt. Col. George Orr's book C3I: Combat Operations (US Air Force Press). We also discussed how to develop multiple ways to intervene and how to decompose an objective to allow us a stepwise approach to reach our final objective. Our goal was to increase our chance of success while simultaneously decreasing her chance of failure.

We looked at conflicted decision-making as described by Irving Janis with our focus on vigilance where we violate each new approach and if it is not work we go back to what we originally were doing. We did not want to fall into hypervigilance where we try methods and, if they do not work, we try more methods and continue trying things. When this happens, we end up treating her treatment.

Finally, we learned useful biases and heuristics. Specifically, I found availability, representativeness, confirmation bias, over-conservative revision, and cognitive dissonance most useful.

Take a break with Weird Al Yankovich (a rock parodist), one thing I noticed early on for medical school was that if a medical student took a break people thought he or she was disinterested. For residents to take a break was almost considered abandonment of their job. For my public safety background I knew we needed the occasional break to perform at peak function when an unexpected demand occurred. We had all operated at intense levels of fatigue and knew the dangers. It was difficult to have my residents and medical students take a breather now and then.

Another contributing factor to this refusal to take a break is a lack of trust that others will help or would pick up the load, or even could pick up the load. To demonstrate this I realize I need to force them into a break situation we did not discuss medical care and we had to rely on the team to let us know when an emergency occurred.

I brought in my Weird Al Yankovic music video and we listened to it together. In all the time I did this only two residents refused to participate. They left the room to continue seeing patients. The goal here was to demonstrate the ability to rest, the competence of a team they can trust, and the reliance on others to let them know when an emergency occurred.