Rapid Resilience in the Emergency Department
Authors: Nhu-Nguyen Le, MD (@NhuNguyenLe); Andrea Austin, MD (@EMSimGal); Daniel A. Dworkis, MD, PhD (@TheEmergMind) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
It is the middle of a busy shift when you get the call that multiple casualties are incoming from a large fire. Your team scrambles to respond as the first victim, a 23 year old with 30% TBSA burns rolls in. He’s screaming and writhing in pain, and you call for Fentanyl 50 mcg IV. The CRNA at the head of the bed hands a syringe to a nurse who pushes the entire contents of the syringe. The CRNA shouts, “That was 200 mcg of Fentanyl!” You look up in alarm, but it is too late and your patient’s breathing slows then stops all together as the large dose of Fentanyl takes effect. The already difficult situation of a sick patient in a multiple casualty event has now been further complicated by medical error, and your team has suffered a serious setback. Your response in these next moments is likely to not only significantly affect the patient’s outcome, but also have ripple effects on the future performance of your team.
How will you acknowledge the error that was made? How will you refocus your team rapidly to care for the patient?
Background: Defining Rapid Resilience
Resilience is defined as the ability to recover quickly from difficulties. It is an essential skill for both individuals and teams in the emergency department, a work environment that commonly faces high acuity patients, large volumes of patients, and high demands from family, administrators, consultants amongst many other significant stressors.
Individual and team resilience can be fostered either within or outside of the ED. Typically, this requires a deliberate practice that can then be applied to the clinical environment. For the individual, examples of resilience techniques include visualization, breathing, or mindfulness, while examples of techniques to improve team resilience include pre-shift huddles, simulations, or, importantly, debriefs.1
Debriefing after adverse outcomes is a common way to promote team resilience in the ED setting. The objectives and format of a debrief are dependent on the environment and time constraints. Frequently, ED debriefs focus on teamwork, communication, leadership and systems issues that are relevant to a multidisciplinary team. A common strategy is to employ the plus/delta method of debriefing, in which team members describe something that went well (the “plus”) and then something that could be improved (the “delta”).3,4 However, traditional debriefs often take up to 5-10 minutes, and are impractical when errors or setbacks occur during a critical resuscitation or mass casualty incident.
Such circumstances require not just resilience, but rapid resilience. In these cases, where emergency care demands are actively ongoing, individuals and teams need to be able to recover from an adverse event without lessening the pace of the care they continue to provide. Doing so requires a delicate balance–failing to acknowledge and reset after a setback may lead to a deterioration in teamwork and trust, while spending too much time on a debrief can also complicate or even compromise patient care.
While much has been written on resilience in medicine, the term rapid resilience as such has not been used in the context that we suggest here. We define rapid resilience as the ability of the individual and team to rapidly (within seconds) and sufficiently process an adverse event in order to effectively continue acting. Considering the level of challenges we face in the ED, this is a tall order.
Once a critical incident has occurred that is time sensitive, the team leader must be able to separate the most important facets of the event that need immediate action from aspects that can be discussed later. The primary goal is somewhere between “minimum viable processing”, which does the minimum debrief necessary to get individual agents and teams back to function, and “maximum possible processing”, which does the most in depth processing possible at this moment given current time and resource. Rapid resilience begins internally with the team leader. From there, the leader can bring the team together to move forward and care for the patient.
The R.A.P.I.D. Approach:
To practice rapid resilience, we suggest the following approach that can be accomplished in less than 90 seconds.
R- Recognize Critical Incident and Reset
As team leader, once you have recognized the critical incident you must rapidly process and personally reset. Your team needs your guidance and leadership. For many, this may be an internal “F***, that just happened.” This allows a discharge of the emotional response that nearly all humans have when a challenging situation occurs, and it ensures you do not avoid the situation at hand.
It is inevitable that when a difficult situation arises, you are going to have a stress response that includes activation of your sympathetic system. As our sympathetic system is activated, the amygdala takes priority over our prefrontal cortex, the site of all of our high level cognitive processing machinery. It is critical that you learn your own stress signals and how to employ a rapid calming maneuver. For some, they may notice jaw or other muscle tightness, they may feel their heart beat rapidly or hands start to shake. Some strategies for calming include utilizing a mantrum, box breathing, or taking one’s own pulse to regain presence.5 Much of medical training has involved ignoring these cues, and to become a true “Zen master” of resuscitation, you must first learn your stress signals and develop an effective strategy to rapidly calm yourself.
A- Assess Situation and Formulate Plan
Formulate the immediate action items for yourself and the team. When your thoughts lead to emotions or complexities that need further discussion in a debrief to improve team knowledge or address systems issues, tag these thoughts in your mind but push them to the side to stay action-oriented.
P- Prioritize Actions and Assign Roles
Brief your team on what has happened and the planned response. Assign clear roles state prioritization of the tasks to follow. Acknowledge that this is a situation that requires a longer debrief, but for now, we need to keep focused on the case/shift at hand.
Inherent in the above response is compartmentalization. Compartmentalization is a useful technique, but only within the confines of a resuscitation or shift. Over the long term course of our career, our patients need us to process the emotional valence of the difficult events that we work with. In this moment though, what they need is compartmentalization and for us to get back on our feet ASAP. There is absolutely no way to fully process what has happened in the moment, especially when the patient or the next patient needs you and your team. The best we can do, is to acknowledge the difficulty and plan time for ourselves and our teams to debrief these challenging cases later.
I- Instill positivity and compassion
Provide an authentic, positive motivational phrase for the team. “I know this is a difficult situation, I really appreciate everyone doing their best for this patient.” Resilience is linked to a positive attitude. To be resilient, one must believe that things are going to get better, hence a certain level of optimism is required. There are studies from the sports performance world in which athletes that visualize sinking a free throw are better at free throws. Conversely, visualizing missing a basket is associated with worse performance, that can take even more time to unlearn.6 This translates into our resuscitations.
It is inevitable that procedures will be missed, by both ourselves and our team members. We’ve all been there, often in training, when we miss an intubation, and the dynamics of the team around us often determines how likely we are going to get it the next time. Sarcasm and gallows humor are two common defense mechanisms in medicine; these are toxic during difficult situations and can severely negatively impact personal and team performance.
When a setback occurs, for example, missing an intubation, avoid berating yourself. Instead, try something along the lines of, “This is a difficult airway. I am well trained and skilled, I can do this. I’ve been in tough situations before and I will get through this one too.” It is important to acknowledge that we can still grow through reflection and debriefs without inflicting self or team humiliation or shame. Shame and humiliation can lead to the team leader and team entering a spiral that results in poor communication, lack of trust, and ultimately endangers patient safety.
Once the dust has settled, we must debrief and review from an intellectual perspective to determine what can be improved in regards to teamwork, communication, leadership, equipment and other systems issues.
Upon realizing the patient received an overdose of Fentanyl, you took a deep breath. You have a brief internal, “F***. Not good,” and then you reset yourself mentally using a mantra you practiced ahead of time. Next, you turned to a problem focused approach, acknowledging that an error had occurred to your team, and stating clearly that the priority and focus now is to oxygenate the patient. You assign immediate action roles to the CRNA, RT, and RN, noting that you will all discuss the case further later. Finally, as your team jumps into the new direction of their action, you serve up some much needed positivity, saying, “I know this is a difficult situation, I really appreciate everyone doing their best for this patient. Let’s get it done.”
Your team bags the patient and supports him through the Fentanyl until he regains the ability to breath on his own. His injuries are addressed, and he is admitted to the trauma service for further care. Later, you regroup the team for a focused debrief on the case. The case is discussed for approximately 20 minutes. This is a longer than usual debrief in the ED setting, but this was a significant error that warrants longer processing. Through this extended debrief communication and system issues are uncovered and a plan is developed to improve patient safety. Additionally, there is a collective emotional release from the group. The error was acknowledged and the team departed the shift with trust in each other intact and a sense of pride that they took the time and courage to improve patient care.
- Traditional resilience techniques and practices are often difficult to apply to setbacks that occur during time-sensitive situations such as a critical resuscitation or mass casualty incident.
- Rapid resilience as the ability of the individual and team to rapidly (seconds), sufficiently process the event to act in response to a difficult situation.
- Over the long term course of our career, our patients need us to process the emotional valence of the difficult events that we work with. In critical moments though, what they need is compartmentalization and for us to get back on our feet as soon as possible.
- Consider the R.A.P.I.D. approach as a focused method to quickly and productively process and move forward from difficult events during on-going high pressure situations.
- Martin, Daniel. Resilience Training, Mindfulness Can Ease Emergency Department Stress. 14 Mar. 2017, acepnow.com/article/resilience-training-mindfulness- can-ease-emergency-department-stress/.
- Schmidt M, Haglund K. Debrief in Emergency Departments to Improve Compassion Fatigue and Promote Resiliency. J Trauma Nurs. 2017;24(5):317-322. doi:10.1097/JTN.0000000000000315
- Walker, Craig. “STOP 5: STOP for 5 Minutes” – Our Bespoke Hot Debrief Model. 1 Nov. 2018,https://www.edinburghemergencymedicine.com/blog/2018/11/1/stop-5-stop-for-5-minutes-our-bespoke-hot-debrief-model
- Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More Than One Way to Debrief: A Critical Review of Healthcare Simulation Debriefing Methods. Simul Healthc. 2016;11(3):209-217. doi:10.1097/SIH.0000000000000148
- Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Ann Emerg Med. 2017;70(6):884-890. doi:10.1016/j.annemergmed.2017.03.018
- Asken, Michael J, Grossman, Dave with Christensen, Loren. Warrior Mindset. Human Factor Research Group, Inc. 2012.