After reading responses to EMCrit’s tweet on BTSF (beat the stress, fool), I realised there’s little out there which helps paramedics and those practicing in the prehospital care environment actually manage when they’re out of their depth.
Generally we’ve come to accept that we’re going to get better by immersion and experience, but this doesn’t do any service to patients or peers. We know it’s collective critical incidents which build first responder stress, and resilience, when managed properly.
BTSF (breathe, talk (self), see (visualise), and focus is a tool for managing these instances, developed on research, but is likely only useful when you’ve practiced first. Its for all of us, from the first responders being talked through a chest decompression via Clinical Consult, or the ICP doing the only emergency cric of their career, to the thirty year vet who is now working on their grandfather. Critical stress training is a tool we can practice, to help us through stressful situations where we’re truly out of our depth.
Breathe- firstly gives a second to stop, and reassess if this is actually what you want to (or need to) be doing. A self assessment, and pre task immersion pause is proven to decrease human error. The increase in circulating oxygen makes you feel OK too…
Talk (self)– this has two steps: mantras and sayings to boost confidence in yourself and team. Beat the stress, fool, is one. Slow is smooth, smooth is fast is another, a personal favorite. Secondly, just thinking through the process aloud to ensure everyone is on the same page. This is particularly important in the RSI or multiple task extraction setting.
See– actually have an understanding of what you’re doing, from start to finish. Encourage others to do the same, and make sure your visualisations are similar. Foresee and pre-empt errors to pre-manage them, and only when you’ve got a fair picture in your head, do you proceed.
Focus– actually give your full attention to the task you need to be doing. Hand off scene command, give others tasks to manage, so you can perform your primary task. A lot of negative stigma is associated with task immersion, but if managed well it can achieve excellent outcomes.
Poor outcomes, in particular avoidable harm or mortality, are rarely the result of poor staff performance, but a reflection of poor or dated training failing hard working, well intentioned staff. US Army review of battlefield deaths suggested approx 25% of battlefield deaths are survivable, so why are they occurring? Human error and access to care. In no way can we be replacing definitive care, but for those who ARE definitive care, or are performing skills outside scope or active way about their pay grade, I hope the above guides you through your next sticky situation.
Performance through professionalism.
1) Britt, T., & Jex, S. (2015) Thriving Under Stress: Harnessing Demands in the Workplace. Oxford University Press: New York
The introduction chapter is worth a read.
2) Lauria, M., Gallo, I., Rush, S., Brooks, J., Spiegel, R., Weingart, S. (2017) Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Annals of Emergency Medicine http://dx.doi.org/10.1016/j.annemergmed.2017.03.018
3) Cornthwaite, K., Edwards, S., Dimitrios, S. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics & Gynaecology 27 (4): 571–581, doi:10.1016/j.bpobgyn.2013.04.004
4) Postma, J., Oldenholf, L., Putters, K. (2015) Organized professionalism in healthcare: articulation work by neighbourhood nurses. Journal of Professions and Organization 2 (1) DOI: https://doi.org/10.1093/jpo/jou008
5) Kotwal, R., Montgomery, H., Kotwal, B et al., (2011) Eliminating Preventable Death on the Battlefield. Archives of Surgery 146(12): 1350-1358. doi:10.1001/archsurg.2011.213