Episode 346: What Military Human Factors Training Can Teach Critical Care Teams with Drs. Lauria and Vahil

0:13 [SPEAKER_00]: Hello and welcome back to Accract. [SPEAKER_00]: I'm Jen Wolpa and I am thrilled to have a fabulous show today. [SPEAKER_00]: I've got two amazing guests. [SPEAKER_00]: We are going to talk about what military human factors training can teach critical care teams. [SPEAKER_00]: I've got with me, Dr. Mike Loria, who's an assistant professor in the Department of Emergency Medicine, the sections of course.

0:30 [SPEAKER_00]: critical care in EMS at the University of Washington in Seattle. [SPEAKER_00]: In 2005 after college he enlisted in the Air Force, completed the rigorous para-rescue training pipeline and served at the 321st Special Tactics Squadron. [SPEAKER_00]: He later enrolled in medical school and completed an EM residency in fellowships in both EMS and critical care.

0:48 [SPEAKER_00]: And he now works clinically in the Cardio Thurazic ICU at the University of Washington Medical Center, Mont Lake, in the ED at Harborview Medical Center, and in the Harborview ICU as an ECMO program faculty member. [SPEAKER_00]: He also serves as director of University of Washington Mobile ECMO Program.

1:03 [SPEAKER_00]: And also, I have Dr. Neil Vahil, who is a pulmonary and critical care medicine fellow here at Johns Hopkins, and a former U.S. Army officer. [SPEAKER_00]: His interests include critical care leadership, ECMO, and applying lessons from the military, and other high-reliability organizations to improve team performance and decision-making in the ICU.

1:21 [SPEAKER_00]: So this is going to be a fabulous discussion with these two experts on military training and military human factors and how they imagine we can improve our teaching and use of critical care with learning from what they learned in the military. [SPEAKER_00]: So the idea here is that [SPEAKER_00]: that the ICU really runs on two kinds of thinking.

1:38 [SPEAKER_00]: And people who are familiar with thinking fast and slow, Daniel Hanuman's book will know what I'm talking about. [SPEAKER_00]: System two is slow, analytic, deliberate, system two values building a differential and weighing the evidence, but system one is fast. [SPEAKER_00]: It's pattern-driven, it's reaction.

1:52 [SPEAKER_00]: It's useful when you are dealing with a patient who rapidly decompensates and there is not time to deliberate, you just have to react. [SPEAKER_00]: Medical education is well designed for system 2, but is pretty close to just silent on system 1. [SPEAKER_00]: But the person leading a resuscitation in the moment in that stressful environment is operating almost entirely in system 1, but we really, in medicine, we leave that development of that capacity to the slow accumulation of cases over a career.

2:16 [SPEAKER_00]: You build this repertoire of, I've seen it a million times, so now I can react fast, but that takes time, it doesn't come quickly. [SPEAKER_00]: The military, though, as I've learned from these guys, takes a different approach, it forces the repetitions through simulation, graded stress exposure, and disciplined debriefing.

2:33 [SPEAKER_00]: As a result, it deliberately develops the heuristic that fast thinking depends on and then evaluates it. [SPEAKER_00]: And that paradigm has been translated really effectively into medicine in anesthesia. [SPEAKER_00]: And it worked. [SPEAKER_00]: We do this really while in the operating room, and preparing for the operating room.

2:47 [SPEAKER_00]: But in critical care, it never really took on the same amount of success, and it never really happened to the same extent. [SPEAKER_00]: And so we're going to talk about how maybe critical care could do better, and I'm really thrilled to have these two experts here, Mike, and Neil, welcome to the show.

3:01 [SPEAKER_01]: Oh, thank you so much. [SPEAKER_01]: Thank you so much. [SPEAKER_00]: Appreciate it. [SPEAKER_00]: Let's start with some stories of kind of what got you interested in this. [SPEAKER_00]: You know, what are some things from your experience in the military that made you think this is something I want to take further?

3:16 [SPEAKER_01]: Yeah, thanks a lot, Jed. [SPEAKER_01]: I think the genesis for me in the military specifically, and this is before I came to critical care medicine, is as a lieutenant, I was assigned to initially assigned to a mechanized volunteering where we commonly do these live fire exercises before we're actually forward-trained to deploy.

3:36 [SPEAKER_01]: And, [SPEAKER_01]: We would brief these plans repeatedly, every crew, when we'd brief them, we'd understand if the individual task. [SPEAKER_01]: But the rehearsal on the actual range was where we learned whether or not the whole system worked. [SPEAKER_01]: And I can remember once an area where the plan required one element to shift its fires while another element moved forward to engage the next set of targets.

3:58 [SPEAKER_01]: And on paper, the sequence was clear. [SPEAKER_01]: And it was simple. [SPEAKER_01]: We all seemed like we understood it. [SPEAKER_01]: But during the rehearsal, it became pretty obvious that the trigger for shifting fires was ambiguous. [SPEAKER_01]: And... [SPEAKER_01]: One of the crews could have interpreted the call as permission to continue engaging while another believed it was safe to move.

4:16 [SPEAKER_01]: And this is potentially a catastrophic failure. [SPEAKER_01]: And it didn't have anything to do whether either a crew knew how to operate the vehicle we were training on. [SPEAKER_01]: The problem was the system. [SPEAKER_01]: It was communication. [SPEAKER_01]: It was sequencing. [SPEAKER_01]: And it was failure of shared understanding.

4:32 [SPEAKER_01]: So before we went live, we clarified the trigger. [SPEAKER_01]: We standardized the call. [SPEAKER_01]: and we rehearsed the transition again, and that's what led to success, and so that was really the initial period during my military career, where I realized how crucial simulation training was, how crucial training these human factors, training success and these human factors principles was for our success in our safety.

4:57 [SPEAKER_00]: Yeah, thanks Neil. [SPEAKER_00]: Mike, how about you? [SPEAKER_02]: Yeah, for me, it was actually someone similar experience getting out of the military, and I started working [SPEAKER_02]: and doing critical care transport, and when I would train in the hospital and see what was going on the ICU, we both spark my interest to go back to medical school and do critical care, but I also noticed it's very interesting, very interesting things the way people were taught to perform under pressure and make decisions in the face of, uh, [SPEAKER_02]: of crisis and it was absolutely fascinating to me to start contrast between the military special operations world and how it was taught in the ICU and the emergency department in civilian EMS and critical care transport.

5:42 [SPEAKER_02]: And the bright light actually was the anesthesia literature and a lot of my mentors in anesthesia, told me about the ideas, anesthesia, resource management, or anesthesia crisis resource management, and how that had been developed by GABA and others, and I was like, man, it's here. [SPEAKER_02]: Like, it exists in medicine.

6:00 [SPEAKER_02]: It's sort of, you know, disillusioned and burning in the background with some knowledge and it's why aren't we doing this on a larger scale and all of those aspects of root resource management. [SPEAKER_02]: decision-making communication the way we teach people how to think and approach problems.

6:15 [SPEAKER_02]: And so that sort of spark this passion for exploring it in other clinical circumstances. [SPEAKER_00]: Yeah, fabulous. [SPEAKER_00]: And you know, you both are coming or came to critical care through a military background. [SPEAKER_00]: And so you were able to bring some of this with you.

6:30 [SPEAKER_00]: And some of that I know is about what I kind of set up front system one and two. [SPEAKER_00]: So let's look a little bit about that. [SPEAKER_00]: What are they maybe give a little more detail than I gave? [SPEAKER_00]: Like what exactly do you think people need to know about system one and system two and why does that important for an intensive [SPEAKER_01]: You know, I think that people who work in ICU medicine have this unique role where, you know, if you're working as a rheumatologist or in a phrologist or many other disciplines, particularly within internal medicine broadly, you can exercise exclusively system to thinking.

7:05 [SPEAKER_01]: Whereas if you're in intensive as to have you need to be good at system one thinking, and system two thinking. [SPEAKER_01]: And broadly what they are, the system one is this fast parallel magnetic and pattern recognition, where a system two is slow, it's effortful, it's analytic, the vocabulary was popularized.

7:23 [SPEAKER_01]: popularized by a dandel conumen, but where if it's in the ICU, a system too is classically morning rounds. [SPEAKER_01]: It's engaging in the differential, it's integrating the literature system one, on the other hand, it's the first 90 seconds of a deteriorating patient. [SPEAKER_01]: It's you recognizing the picture, it's not you defining all the different options and all the potential, all the potential things within the differential that could be happening to the patient.

7:54 [SPEAKER_01]: And you know, importantly, this is. [SPEAKER_01]: This is a type of compiled expertise and it has to be trained the same way that it's trained in the military. [SPEAKER_01]: And this is what is ultimately needed to enhance both system one and system two competencies. [SPEAKER_01]: And they both inform and reinforce each other.

8:10 [SPEAKER_01]: And ultimately the ICU is about building that hybrid, that hybrid clinician. [SPEAKER_01]: Someone who's committed both exercising system one thinking and system two thinking and about recognizing when each vote of thinking is most valuable. [SPEAKER_00]: Yeah, and I'll tell you, one of the ways we see this really star clearly is sometimes we have people with a research background, okay, they're trained in research.

8:33 [SPEAKER_00]: And that is about a system, too, as it gets, right? [SPEAKER_00]: I mean, you have a question, you spend years investigating the question, reading and detail, everything written about that question. [SPEAKER_00]: you do your own experiments and think about how they fit in, you have all the time to do it that you want.

8:48 [SPEAKER_00]: And it is, can be a real shock to the system of someone who's been, their brain has been trained that way to be in a code in the ICU or just a deteriorating patient in the ICU because you cannot stop and look up a bunch of articles and think it through and talk to a bunch of people about it.

9:04 [SPEAKER_00]: You just have to go and that's such a stark difference. [SPEAKER_00]: And so, you know, those people, [SPEAKER_00]: need help to develop those skills because it's not inherent certainly a research training and honestly it's not I think that common in just medical school training either Yeah, I think I think the way we [SPEAKER_01]: I, you know, to your point, I think the way that we train in medical school is, and Mike and I were talking about this yesterday, we learn so many basic principles of physiology, of pharmacology, of biochemistry, and then we fill in these system-1 tasks afterward.

9:40 [SPEAKER_01]: So, you know, you can imagine being inundated with so much data on the ICU and, you know, having this background, and then so almost being paralyzed by the decisions that you have [SPEAKER_01]: Whereas, I think, you know, the opportunity of being able to teach a critical care course to some range of medics a couple of weeks ago, what I recognize is that they were really quick and being able to identify the exact interventions that needed to happen quickly, expeditiously, stabilizing the patient.

10:09 [SPEAKER_01]: We fill in the physiology for them afterwards, a very effective way of training system [SPEAKER_00]: And is it accurate to say there isn't like one is good in the other is not right you need both and what about you know what am I right when I say that medical school doesn't do a great job of training system one do you think that's accurate or no I would say it's a hundred percent accurate [SPEAKER_02]: It's very interesting coming from the world at academics seeing how these types of thinking are perceived.

10:45 [SPEAKER_02]: For a couple of reasons. [SPEAKER_02]: One, really, if you think about doing a kingdom in very popular book, thinking fast and slow, brought this, I think, into the popular light. [SPEAKER_02]: I mean, his Nobel Prize is actually in prospect theory. [SPEAKER_02]: So it wasn't about necessarily system one and system two thinking.

11:03 [SPEAKER_02]: And this was outside the scope of outside of like researchers and people who focus in cognitive science and crew research management and human factors because of a broader into the public light. [SPEAKER_02]: And I think one of the unfortunate ways that it was categorized in that book was that [SPEAKER_02]: system one was kind of, it fools you, it tricks you, it's bad, it's fraught with bias, and I think people walk away from that book with that idea.

11:28 [SPEAKER_02]: And especially from academics, I can make you mention like your whole training, your neurological and cognitive architecture is developed since you're a fetus, and definitely like medical school to focus on system 2, but it's like you point it out, just doesn't work in some circumstances, and it's been maligned in a lot of ways, [SPEAKER_02]: You need both, like you point in that.

11:50 [SPEAKER_02]: And there's some research that demonstrates if that's appropriate. [SPEAKER_02]: They overlap. [SPEAKER_02]: So it's not always just like black or white system one or system two. [SPEAKER_02]: You can wrap the tab switch between the two, the way your brain's thinking about things. [SPEAKER_02]: There's some overlap in there.

12:02 [SPEAKER_02]: And actually, there's actually some very good research on the side of the whole system one. [SPEAKER_02]: thinking paradigm, so Gary Klein was actually a psychologist or he worked for some period of time, and is written extensively on this concept of recognition, prime, decision-making, and how it's actually beneficial.

12:23 [SPEAKER_02]: And so there is benefit to both, and in fact, [SPEAKER_02]: These two like super advocates for either science, someone in system two came together and wrote an amazing paper called the failure at this degree. [SPEAKER_02]: Where they actually outlined when these systems work well and when they actually don't.

12:45 [SPEAKER_02]: And in this paper like they come up with the limitations. [SPEAKER_02]: and the benefits of each of these types of thinking, if you will. [SPEAKER_02]: And if you look at it and heat it very carefully, which you realize is a lot of what we do with in critical care in anesthesia and emergency medicine in EMS, you have someone who's critically ill and rapidly deteriorating.

13:07 [SPEAKER_02]: What it turns out is there's actually some benefit probably to system one, although it hasn't been respectively or is prospectively analyzed because both of them seem to agree that natural systems where you can observe something like Bible signs, watching our territorial line, systems where you can perturb it reliably, give something left for and give some noir at B, watch the blood pressure come up, even eye in a choke, watch the pulse, but like [SPEAKER_02]: These are reliable biological systems that follow the laws of nature and physics, developing patterns that you see to some one-turn blue and start gasping like you know that's a problem.

13:45 [SPEAKER_02]: As opposed to [SPEAKER_02]: Man made systems gambling things like, you know, in the military, a classic example will be counter nuclear proliferation. [SPEAKER_02]: It's hard to like use system one thinking is probably a bad idea. [SPEAKER_02]: When you're trying to think about something that someone else is thinking about knowing that they're thinking about what you're thinking about terrible idea to use system one and shoot from the hip.

14:05 [SPEAKER_02]: So, it's fascinating to see how this has been developed and traditionally an academic medicine in medical school in particular. [SPEAKER_02]: I think some of the literature has been slightly misinterpreted if we took it as a whole and started thinking about how we can apply system-1 training and education.

14:25 [SPEAKER_02]: We would have a much more ideal system, especially in acute care specialties. [SPEAKER_00]: Yeah, absolutely agree. [SPEAKER_00]: And the other thing that's interesting is the only way to build system one is to get feedback. [SPEAKER_00]: And we'll talk about this on your practice. [SPEAKER_00]: But of course, as a tool go on day has written about, as soon as you finish training, you never again get feedback on your practice.

14:50 [SPEAKER_00]: You can spend an entire career in as whatever special to you are and not ever have anyone watching you and saying here's what you could have done better Trainies get it and I tell our trainees all the time you're like milk it while you've got it because it goes away And that's a shame and it does prevent that, but the military I think does this better and so tell me about that What is the military do to build fast thinking deliberately and to help people build those skills quickly?

15:17 [SPEAKER_01]: Yeah, I think in the military, it's fairly simple. [SPEAKER_01]: The manufacturer, the repetitions, you put people on these realistic, consequential, high-stress situations. [SPEAKER_01]: Make sure that there's enough pressure applied, and then you debrief in a structured way, all of these events afterwards.

15:33 [SPEAKER_01]: So the patterns start encoding over time, sort of develop this library over time, rather than waiting on whatever cases happen to arrive, actually, in form of thinking. [SPEAKER_01]: I think stress and oculation is the other half of this and you get great exposure to stress to enable you to cope with this effectively over time not so much that it overwhelmed you but enough that you're able to function in a high stress situation reliably over over the course of your training.

16:03 [SPEAKER_01]: I think this is present in [SPEAKER_01]: standard military selection and systemic pipelines. [SPEAKER_01]: I think it's certainly I think Mike can speak more to what this like in pair rescue selection for instance, but I think this is this is something that this is a principle that is applied on probably across the military [SPEAKER_00]: So the key here on hearing you say is both deliberate practice so getting the simulated experiences and then the debrief and feedback on how it went so that you can then build your skills and build those patterns and make sure that you are building the right patterns.

16:38 [SPEAKER_02]: Exactly, I think those are absolutely two big parts of it. [SPEAKER_02]: I just wanted to comment really quick on some of you said Jed, which is like it's like the dirty little secret of becoming an attending Like one day you're a fellow at one institution and the next day you show up and people just listen to you They expect the trigger and let me know as you say saying well, you really stupid and people like who the hell is this guy and what is he thinking um like it's just [SPEAKER_02]: It's just taken as gospel and it's crazy sometimes and there is no one looking over your backs.

17:10 [SPEAKER_02]: You're not getting the feedback and what I think compounds it even more, unless you're in a procedural special, if you were as an attending, you're doing things regularly. [SPEAKER_02]: Like if I'm in the ED or the ICU, for example, less and more nights or in the CTSC where our APPs do not intubate patients, like my airway management went from like hundreds and [SPEAKER_02]: maybe not as much as an anesthesia training, but more than 500, I think I clocked over the course of COVID, to like now it's very, very frequent almost.

17:41 [SPEAKER_02]: like I have to find time and occasionally be like okay I think I need to do this one number one because I think they're they're super super sick and we do need the fastest learn gossipest on this one but um and most experienced but uh just like staying in practice so not only are you you know elevated in that sense but you're uh what you're actually doing procedurally sometimes is limited it's crazy [SPEAKER_02]: And the military is the opposite.

18:07 [SPEAKER_02]: There's always feedback circles. [SPEAKER_02]: And those feedback circles are often of your peers. [SPEAKER_02]: It would be like doing a resuscitation with five attending. [SPEAKER_02]: So like a fighter debrief year of in one of those special operations, debrief permission. [SPEAKER_02]: The way we sit down and go through those, you are constantly getting feedback.

18:26 [SPEAKER_02]: And you have to be very open to it. [SPEAKER_02]: I think that makes you add the level of humility, but it also adds continual feedback to things. [SPEAKER_02]: And lastly, I'll touch on the idea that I think it is trainable. [SPEAKER_02]: I think a lot of people think that over time, yes, you can adapt to these things in that too.

18:42 [SPEAKER_02]: But I think there are mechanisms of both in the civilian and military side, that demonstrate that it might be feasible. [SPEAKER_02]: So going back to the work of, for example, Danny Caineman, if you want to look at some of the publications, [SPEAKER_02]: and some of the stuff he said he'd on a process called Shadow Boxing.

18:57 [SPEAKER_02]: It is a very potent tool for actually developing that. [SPEAKER_02]: So I'll never forget, and I'm sure both of you can share similar experiences, where I remember one of the first ECPR cannulations that I did as the second year resident. [SPEAKER_02]: The attending was like walking me through things.

19:13 [SPEAKER_02]: I'm like trying to advance this cannula and he's like, you feel that resistance, that's okay, push through that. [SPEAKER_02]: You feel how that wire is not moving, that's not good. [SPEAKER_02]: Stop for a second and we gotta figure this out. [SPEAKER_02]: when we put the patient on, I'll never forget.

19:25 [SPEAKER_02]: He said, look at the A-line watch what happens to this pattern because his blood pressure is going to go up. [SPEAKER_02]: Everything is going to get perfect and then you'll see all of his blood goes through this plastic and then his blood pressure will come down again. [SPEAKER_02]: So never do this, never completely turn off the pressure, never completely do that and watching this pattern unfold.

19:41 [SPEAKER_02]: It was like I was like boxing next to him, watching his every move and that's where the term shadow box comes from and it's very powerful and I'm sure people and other procedural [SPEAKER_02]: that really stick with us through training and even into attending, so I think it's possible. [SPEAKER_00]: Yeah, absolutely.

20:01 [SPEAKER_00]: You're right on. [SPEAKER_00]: Those are such important experiences and help us start building those schema for ourselves. [SPEAKER_00]: Tell me a little bit about the performance psychology literature and how this informs what you're doing in the military and what we could be doing in critical care.

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21:13 [SPEAKER_00]: We rely on trulern for our test prep, but I recommend you do the same trulern.com and use code acrack. [SPEAKER_02]: So I think we're going back to like the special operations training and world performance. [SPEAKER_02]: I thought it was very interesting over time how many of my colleagues in that world developed these skills.

21:39 [SPEAKER_02]: They adapted and there's some very fascinating literature in the cognitive and neuroscience about how [SPEAKER_02]: Yes, we can adapt to that over time. [SPEAKER_02]: There's even some suggestion on functional MRI studies of continual exposure of very challenging tasks, results in less blood flow to the hippocampus and less activation of the HPA access and super fascinating stuff that really we need to dive into some a little bit more about neural modulation.

22:07 [SPEAKER_02]: and the ability to express very neuro-significant neuro-modulatory peptides over time that allows you perhaps control that stress response. [SPEAKER_02]: But what was very interesting to me is people had developed, even though they didn't know what they had adapted various specific skills, things that they were doing like athletes, like pro athletes that would allow them to at least to a certain extent mitigate some of the stress response.

22:35 [SPEAKER_02]: And so the fascinating part was transitioning as a civilian. [SPEAKER_02]: When a lot of people adapted these to functional tasks, it fell naturally into their workflow. [SPEAKER_02]: So you're about to assault a building and people would express how they would use mental practice or box breathing techniques.

22:52 [SPEAKER_02]: But they didn't call it that, because they didn't know the literature. [SPEAKER_02]: They just adapted these techniques. [SPEAKER_02]: Well, flip on, it's head fast forward about eight years, it turns out when you actually, when I was a civilian, go back to look at this stuff, there was literature on this stuff.

23:04 [SPEAKER_02]: People had actually studied many of these tasks, and we looked at this, the challenge being on this civilian side hadn't been adapted very well, so you'd have performance psychologists come, and they tell you it was like a paramedic, or like a resident, we have to ground yourself, [SPEAKER_02]: You know, touch a rock or some grass and now there's some dial of literature that but functionally like what are you and I going to do we go step outside the ICU and like go to the park and like sit down and touch the grass when someone's dying like you just can't do that and so we looked at was.

23:37 [SPEAKER_02]: sort of some of these techniques that you could like work into a workflow like box breathing like positive self-talk and reframing cognitive reframing like mental practice, specifically, especially when an involves technical skills, airway management, cannulation, surgical procedures, all that stuff really good.

23:58 [SPEAKER_02]: So I think there are a handful of things that you can adapt to your practice [SPEAKER_02]: It's not the only solution, but I think it's a big part or a smaller part of the bigger picture solution that can help in those situations. [SPEAKER_00]: Yeah. [SPEAKER_00]: Let's talk about what really we can translate from the military.

24:22 [SPEAKER_00]: So, another thing that we haven't touched on yet, I think are really the communication practices, one thing that my understanding in you guys, of course, is that the military really uses and teaches really good close loop communication. [SPEAKER_00]: Tell me a little bit about that. [SPEAKER_00]: How does the military teach it and what translates over into the ICU?

24:40 [SPEAKER_01]: So, you know, when I thought about this retrospectively, I thought about four key things that had some crossover from the military, you know, Mike and Oakley expand on this as well. [SPEAKER_01]: But one was closely communication. [SPEAKER_01]: And from the minute that you hit the ground training in the military, closely communication is very much emphasized.

25:01 [SPEAKER_01]: every high performance team does this. [SPEAKER_01]: Every time you give an order, every time you ask for something, it should be repeated back to you, because there should be no confusion when you're dealing with high-consequent situation, with a high-consequent situation, or when live-serve-risk.

25:17 [SPEAKER_01]: There's the concept of commanders intent. [SPEAKER_01]: This isn't necessarily have to be tied to some more of our training hierarchy, but this can be that any sort of ICU leader, for instance, [SPEAKER_01]: can over constate the purpose, the desired entity, and not just the task, and that allows for a couple things that allows for, in a decentralized way, you were team to adapt whenever the plan breaks down as it often does.

25:43 [SPEAKER_01]: But it also signals your primators and how you can adapt within those primators and went to them. [SPEAKER_01]: What the Trader should be to ask for help. [SPEAKER_01]: So an example, Mike and I have been discussing a couple days ago was, for instance, if you're intubating a physiologically challenging airway, we had an instance a few weeks ago in the ICU where we were intubating a patient who had EF about 10%.

26:11 [SPEAKER_01]: And prior to the intubation, you know, sort of discussed our, you know, I discussed my airway plan. [SPEAKER_01]: And then doing that, you know, talk to the residents and I was like, right, I think expect to happen is an immediately post intubation, what pressure is going to drop. [SPEAKER_01]: We need to have pushed us the pressures available in the interim here to think that, you know, we need to instruct positive pressure in this way.

26:33 [SPEAKER_01]: And sort of talking through the physiology, what we expect to happen to the, you know, [SPEAKER_01]: I think that's sort of allowed, you know, the resident from the other books in the room, including the nurses, the respiratory therapists, to have some sort of share and understanding of what was going to happen.

26:50 [SPEAKER_01]: So that's the commanders intent enabling shared understanding of often times ten U.S. clinical situation. [SPEAKER_01]: The other one is the back breathe, so sometimes you're explaining what your plan of care is for a critical ill patient and allowing your team, you know, resident for instance to restate the plan in their own words.

27:13 [SPEAKER_01]: So that really ensures that they truly understand what you're communicating to them about the plan of care for the patient. [SPEAKER_01]: And what's actually happening to the patient at the time that you're on service. [SPEAKER_01]: This is something that we use constantly in the Army. [SPEAKER_01]: I was mainly at the small unit level.

27:36 [SPEAKER_01]: And so every time we break the plan, every time we briefed, for instance, an operations order for how we were going to maneuver a team, [SPEAKER_01]: We would all with make sure that each section leader back rift the plan to the pletail leader that way we all ensure that we have an understanding of the plan and and [SPEAKER_01]: And then battle drills, I mentioned this at the beginning of the episode, but battle drills are these rehearsed standardized responses to common situation and, you know, rehearsing and doing regular battle drills, regular simulations allows you to ensure that there's no sort of danger and it allows you to actually determine if there's any actual, actually dangerous situation that you may end up avoiding.

28:25 [SPEAKER_00]: Stay with us. [SPEAKER_00]: We'll be right back. [SPEAKER_00]: All right. [SPEAKER_00]: And we're back. [SPEAKER_00]: Yeah. [SPEAKER_00]: This is so key. [SPEAKER_00]: And you know. [SPEAKER_00]: And from time to time, you always hear about these M&Ms, right? [SPEAKER_00]: These drug errors, where somebody, I remember one when I was a resident, where one of my co-residents was a CA1, and the fellow said to give some nitroglycerin.

28:53 [SPEAKER_00]: Two patients was very hypertensive in the OR. [SPEAKER_00]: And the resident didn't know what some meant and pulled out the vial, which I think the vial was, [SPEAKER_00]: 20 milligrams or something insane, you know, 20,000 mics. [SPEAKER_00]: And figured, well, you know, we give the whole vile of things like Rocky Ronnie.

29:12 [SPEAKER_00]: I'm so maybe it's the whole vile. [SPEAKER_00]: And so pulled up the whole vile and gave the whole vile and the patient coded and luckily the patient did okay in the end. [SPEAKER_00]: But, you know, that could have been prevented through a saying, okay. [SPEAKER_00]: So, uh, [SPEAKER_00]: First of all, the commander being much more intent, I want you to take that, I want you to pull it up and dilute it into this and then give this much.

29:33 [SPEAKER_00]: And the readback, the back brief, I'm saying, okay, so my understanding is you want me to give, you know, 200 mics, which is going to be diluted in the given this way. [SPEAKER_00]: And then, of course, practicing that. [SPEAKER_00]: So we are high, well, it's practice. [SPEAKER_00]: So we are high, hypertension in the OR, right?

29:48 [SPEAKER_00]: Whether it's through talking it through or actually simulating it, what are you going to do? [SPEAKER_00]: What are you going to pull up so that everyone has that ready to go? [SPEAKER_00]: So there's a million examples like that, but I think it really makes a difference. [SPEAKER_00]: Not assuming people know what you mean, making sure that you are being specific about what you want and that people are then clarifying it back to you.

30:08 [SPEAKER_00]: Anything to add there, Mike? [SPEAKER_00]: Oh, no. [SPEAKER_01]: I was going to say, you know, there are so many, we're inundated with so many alerts and questions and things that we have to be aware of over an ICU, part of the function of battle drills is to sort of program these processes in your mind that way you can preserve some cognitive bandwidth for when you actually have to exercise system to thinking.

30:33 [SPEAKER_01]: And so I think that battle drills, and they sort of the same function in the military, but battle drills in ICU can sort of ingrain certain micro processes into your mind, so that when you really do need your working memory, you can use it, and you can save your cognitive bandwidth for those situations that really need them.

30:53 [SPEAKER_00]: Yeah, absolutely. [SPEAKER_00]: So let's talk about simulation. [SPEAKER_00]: I mean, that we've, it's come up several times already. [SPEAKER_00]: You can't actually be in crashing patient rooms, you know, all the time to practice. [SPEAKER_00]: So we need a simulation. [SPEAKER_00]: How should we be doing this?

31:09 [SPEAKER_00]: What's the ideal optimal way to get people the training they need to be able to do this well? [SPEAKER_01]: Well, I think, [SPEAKER_01]: The most optimal way to deliver this training is in such a simulation, and that's in the actual unit with the actual team using the actual equipment that you're accustomed to using.

31:29 [SPEAKER_01]: And the one intervention that this is the one intervention that sort of encapsulates all of this at once. [SPEAKER_01]: And this is an environment where you can train all these human factors, principles, and you can sort of really start to view the functioning of your team through a socio-technical lens.

31:46 [SPEAKER_01]: And in the strongest evidence for this, it's finding system failures before they hurt patients. [SPEAKER_01]: There's several different papers that have demonstrated that dozens and dozens of late threats have been identified using inside you simulation. [SPEAKER_01]: And it does something that the simulation center, it can't shrunk really cannot because this is the actual equipment that you're using and you're working with a team that you're generally going to be working with and you're actually having to see how you're functioning, living in your own space and with your own workflow.

32:23 [SPEAKER_00]: Yeah. [SPEAKER_00]: Makes a ton of sense. [SPEAKER_00]: Mike, are there areas where we are doing this well? [SPEAKER_02]: Yeah. [SPEAKER_02]: So I think so. [SPEAKER_02]: I think there's definitely some bright spots that we can turn to that are places that are doing it very well. [SPEAKER_02]: And [SPEAKER_02]: mechanisms that I think are working very well.

32:44 [SPEAKER_02]: I use and various, I would say, I use and various rapid response teams, critical care teams, and recently they're been a couple articles about. [SPEAKER_02]: respond to codes in the cat lab that describe sort of these inside two simulations that are drilling testing the system not designed to necessarily purposely stress people out or test individuals but test the overall system because that's really what makes things safer is a behavioral system equipment interfaces all of the stuff that works to support our providers and patients.

33:21 [SPEAKER_02]: That to me is fascinating. [SPEAKER_02]: Especially in cases like one local case in case one of our ABPs has been doing inside two simulations for cardiac search code and she has them on the floor and rooms, the ICU in rooms, when they're available and I think that's fantastic because it's brought together multiple people to see the benefit of this.

33:39 [SPEAKER_02]: It's tested the system in different places around the hospital that we respond to. [SPEAKER_02]: And as Neil pointed out fundamentally, we shape to how we respond to the communications, the equipment, [SPEAKER_02]: et cetera, et cetera. [SPEAKER_02]: Now that there are challenges with that, and I think there's other bright spots as well that we can absolutely look to on a daily basis.

33:58 [SPEAKER_02]: As we all know, getting all of that together is challenging. [SPEAKER_02]: We can't do it every week. [SPEAKER_02]: If the ICUs and Hopkins aren't much like the ICUs University of Washington, we're like seven people into beds, 10 seconds after their clean, trying to find ICUs space, it's hard.

34:12 [SPEAKER_02]: But there are other ways. [SPEAKER_02]: Just like there's actually some very, very interesting evidence and some publications [SPEAKER_02]: O fidelity simulation can be just as effective in some cases as high fidelity simulation. [SPEAKER_02]: And then you can combine the two. [SPEAKER_02]: A military example is actually Napoleon used to challenge the generals and say, you know, like if the enemy comes over that hill right now, what would you do?

34:34 [SPEAKER_02]: In the military, a similar shadow boxing thing on the special operations career field, if we're flying and the plan is to fastrope, then you might get challenged as a train here and it's safe space and chain. [SPEAKER_02]: What would you do right now if the fastrope became not operational?

34:48 [SPEAKER_02]: We couldn't fastrope. [SPEAKER_02]: We had to land over here. [SPEAKER_02]: We had to use a different alternate insertion method. [SPEAKER_02]: That's testing your brain. [SPEAKER_02]: And I think that we have that then in medicine and subtracted teaching can be done well. [SPEAKER_02]: It can be done poorly under some circumstances, but when done well with a strong, safety and a psychological safety, asking people, you know, and I don't want to say challenging, but prompting our training is an even, you know, colleagues.

35:16 [SPEAKER_02]: He's like, what would you do now? [SPEAKER_02]: Like, hey man, what would you do now is this happen? [SPEAKER_02]: I have an encounter with that problem, but I was wondering about this. [SPEAKER_02]: And challenge your own imagination and their imagination. [SPEAKER_02]: And there is some nearos, the very interesting cognitive science literature on that about this idea of the ability to provide mental practice to yourself and challenge yourself to think about the situations.

35:39 [SPEAKER_02]: So whether this simulation is going on in your brain or whether it's going on in the room in your ICU, I think there's a lot of opportunities. [SPEAKER_00]: But in a degree more, in anesthesia, we have an oral board exam, I think you're doing a emergency medicine too. [SPEAKER_00]: But I'll tell you, preparing for the oral board exam is exactly what you just said.

35:57 [SPEAKER_00]: It is practicing on your own and with other people and doing exactly that. [SPEAKER_00]: What would you do if X, Y, or Z happened? [SPEAKER_00]: And also it is drilling those differentials and actions around the common crisis stuff, severe [SPEAKER_00]: It's profound hypoxemia, profound hypercarbia.

36:18 [SPEAKER_00]: When you see that, what are you thinking? [SPEAKER_00]: And what are you doing? [SPEAKER_00]: And you go over that, preparing for your board, you go over those so many times you can do it in your sleep. [SPEAKER_00]: And I think most people do feel that they are really well prepared, not only for the oral board exam, but for when that stuff happens in real life.

36:32 [SPEAKER_00]: So I agree with you. [SPEAKER_00]: I think it's great to practice it for sure in Cyto, but it can be done low fidelity too. [SPEAKER_00]: Let's talk about why there isn't more of this in critical care. [SPEAKER_00]: What do you guys think? [SPEAKER_00]: Why is this done in anesthesia and in the military, but not as much in critical care?

36:50 [SPEAKER_01]: Well, you know, I think it's for the reason that you and Mike just just mention, you know, a lot of it is we just don't have the beds commonly available to actually run inside you simulations regularly. [SPEAKER_01]: There's an issue of cost. [SPEAKER_01]: There's protected time. [SPEAKER_01]: There's duty hours.

37:04 [SPEAKER_01]: The ICU is never going to stop while you will. [SPEAKER_01]: You run it inside to your simulation. [SPEAKER_01]: There are always patients that need ICU beds. [SPEAKER_01]: So, you know, these are definitely reasons we don't typically have, you know, evaluators that are paid to, you know, oversee these types of simulations.

37:23 [SPEAKER_01]: And, you know, not every single shift in ICU is a mission, not every single mission needs rehearsal. [SPEAKER_01]: But I mean, I think if this can be done, you know, once every quarter, once every month, you know, there's quite a bit of value in that. [SPEAKER_01]: particularly if it's paired with low fidelity simulations, as Mike mentioned.

37:43 [SPEAKER_00]: So let's say that your chair says to you, Neil, all right, you know, I want you to do this, but you have no budget for it. [SPEAKER_00]: So what would you start, you know, next week, if you could do whatever you could do without any extra money, what would you do that you think could move the needle?

37:59 [SPEAKER_01]: You know, I think they're, I think they're, if we have the, if we have the bed's base available, I think that, you know, running at 15 to 20 minutes inside two simulation of, you know, high consequence, but low frequency events in ICU, I think that would be an incredibly powerful way. [SPEAKER_01]: Um, and we, to, to, to train this, this, this type of thinking.

38:20 [SPEAKER_01]: I also think that that's something that doesn't really require any sort of condition to, to a budget. [SPEAKER_01]: Um, [SPEAKER_01]: I think that instituting protocols that are really simple to interpret in institute like pre-shift huddles and nurses do this, but we don't typically get together and say, hey, if there's a code and and bed 8.

38:38 [SPEAKER_01]: Then you run the code, I'll be on the chest. [SPEAKER_01]: I'll help with medication. [SPEAKER_01]: I'll call the family. [SPEAKER_01]: We don't do that. [SPEAKER_01]: We should, you know, instituting pre-shift pedals doesn't cost any money, but it's something that dramatically enhances the dynamics of a team and organizes your team really early on in your shift.

38:56 [SPEAKER_01]: And then I know we're going to talk about this, but conducting regular after-action reviews. [SPEAKER_01]: Every, you know, our organization, every institution, should be a learning institution and every. [SPEAKER_01]: Every unit, every small unit and every team should be a learning team and the way to really integrate these concepts, the way to really learn each shift is to after every significant clinical event, just get your team together and ask everyone what went right, what went wrong.

39:23 [SPEAKER_01]: You know, we Fortune 500 companies have been doing this for years. [SPEAKER_01]: The military does this really well. [SPEAKER_01]: It's required after every major event in the military, after every training evolution. [SPEAKER_01]: And even organizations like the National Health Service and the UK does this.

39:37 [SPEAKER_01]: So this is an easy thing to do, and they can be instituted without any change to budget. [SPEAKER_00]: right now you brought up and this is so key after action review. [SPEAKER_00]: So in the military, that's what you call it. [SPEAKER_00]: How is this done and how is it different from debriefs that we at least think we're doing well in medicine?

40:00 [SPEAKER_01]: My experience thus far and you tell me if yours has been different but my experience thus far is that the way we do the way we review events is typically through a morbidity and mortality conference. [SPEAKER_01]: I don't know that in my experience, I've ever seen those really achieve dramatic behavior or cultural changes, and they are as different in the sense that it's not a critique that's delivered by anyone in particular.

40:26 [SPEAKER_01]: The idea is really just to solicit participation from every single member of the group and ask them really simple questions, what was supposed to happen, what happened, what went right, what went wrong, [SPEAKER_01]: And how can we actually integrate? [SPEAKER_01]: How can we actually institute and implement behavior to change as a result in the flow of what we're learning?

40:45 [SPEAKER_01]: Um, you know, this is, as I said, this is something that's that happens across, across organizations, um, portion of 500 companies have been utilizing this framework for decades now, um, as of the military, and I think these in my experience, um, after every, after every event as a, as a leader in the army, get our entire opportunity, other and ask every single member of the team, regardless of rank, what their experience was, and, um, [SPEAKER_01]: think more than just telling you where your organization can improve, it tells you what everyone's perspective was of that situation.

41:20 [SPEAKER_01]: That really enhances this idea of achieving, we can talk about many times, and this episode already is a shared consciousness. [SPEAKER_00]: Yeah, and so you're asking, what was supposed to happen, what actually happened, why was there a difference between those two things, and what are we going to do differently next time?

41:36 [SPEAKER_00]: And is it a, [SPEAKER_00]: It's meant, if I'm understanding you correctly, it's really not about blame. [SPEAKER_00]: It's about figuring out what went wrong in terms of all the different factors and there's almost always going to be multiple factors, often system factors, and then what can we do to optimize the system so that it goes better next time?

41:54 [SPEAKER_01]: Exactly. [SPEAKER_01]: It's really hard to, you know, at least my experience, it's really hard to, to change behavior, to change culture, and to change the practice and organization, if, if part of that process is, is, is framing, if, if in that, if in that process, blame is, is, is involved.

42:13 [SPEAKER_00]: And why is this so crucial? [SPEAKER_00]: I mean, it kind of seems obvious, but what do you think? [SPEAKER_00]: Why is the debrief for the after-action review so crucial in military operations and should be in the ICU environment? [SPEAKER_01]: It's where broad experiences transit and it's something that actually changes behavior.

42:31 [SPEAKER_01]: Yeah, we were talking about simulations. [SPEAKER_01]: It's a key mechanism to develop something like system one thinking. [SPEAKER_01]: The AR, the after action review, it converts a simulation into a stored pattern instead of just a memory. [SPEAKER_01]: If you just do a simulation without conducting a really strong structure debrief, it's just a time-consuming reversal that no one's gonna learn from.

42:54 [SPEAKER_00]: So this is the difference between practice and deliberative practice, right? [SPEAKER_00]: So if I go out and spend 10,000 hours hitting golf balls, [SPEAKER_00]: And I just hit 10,000 golf balls, whatever. [SPEAKER_00]: Like, I'm not going to get that much better. [SPEAKER_00]: But if I spend those 10,000 hours hitting golf balls with a golf coach who, after every couple of balls, can say, OK, this is where I need you to tweak this.

43:12 [SPEAKER_00]: You see how you did that? [SPEAKER_00]: I need you to make this modification. [SPEAKER_00]: Now, do a few like that, right? [SPEAKER_00]: That is deliberative practice. [SPEAKER_00]: And that's going to be much, much more effective. [SPEAKER_00]: So you need that piece. [SPEAKER_00]: You can't just go do it.

43:23 [SPEAKER_00]: And you need that review that debrief to really [SPEAKER_00]: Absolutely. [SPEAKER_00]: So why isn't this happening after key clinical events? [SPEAKER_01]: You know, the same reason that it's hard to do inside two simulations regularly, time, staffing issues, the one concern here that I can think of as medical legal concerns, it's hard to, it's hard to openly admit that something went badly into into into acknowledge that your team could have done a better job in, in a particular area area of a resuscitation or a deteriorating patient.

44:05 [SPEAKER_01]: There's not, you know, as in so many complicated things, there's not any sort of pre-identified performance standard. [SPEAKER_01]: It's really hard to have a pre-identified performance standard when you're dealing with patients who often have competing physiologies, multi-organ failure.

44:21 [SPEAKER_01]: That's just not something that you can easily develop. [SPEAKER_01]: And so I think that makes a challenging to reliably conduct an after-action review. [SPEAKER_01]: I think that, you know, an AR, an app production review, it's a learning event, it's not an accountability event. [SPEAKER_01]: And I don't know that that's always what we're oriented towards in medicine.

44:39 [SPEAKER_01]: We typically want to assign some accountability that's sort of, you know, inherent in our jobs. [SPEAKER_01]: And so what we typically do in the way we try to ensure that we're learning organizations is through M&Ms. [SPEAKER_01]: And I don't know that I don't know that that's, you know, I feel like in many ways that's oriented towards [SPEAKER_01]: judgment rather than, and people are primed to defend themselves, it's often been the case that aminems that have been to multiple different organizations.

45:08 [SPEAKER_01]: And so rather than learning from your mistakes, you're sort of left trying to defend the decisions that you made for a particular patient, which is not the way it's to generate organizational or institutional change. [SPEAKER_00]: Yeah, and I think it's so important that we, as leaders, as teachers, as attendings, really do a good job of sending that message.

45:31 [SPEAKER_00]: For example, I try to all, when let's say a resident, I don't know, you know, Mrs. the intubation or the A line or whatever, I always try to tell them, look, I'm actually really glad, right? [SPEAKER_00]: If this had gone like that, if there was no issues at all, like I wouldn't really be able to teach you anything today, right?

45:45 [SPEAKER_00]: But the fact that it was difficult, [SPEAKER_00]: that the airway took a while that you didn't get it that's good because it means we have something to learn. [SPEAKER_00]: I can give you some tips on what you can do differently next time. [SPEAKER_00]: So I'm glad this happened and I think setting that kind of get to that learner mindset as opposed to the performance mindset is really key because really all of us in medicine you know if you if you got [SPEAKER_00]: to where we are, you probably have a performance mindset, right?

46:09 [SPEAKER_00]: You were used to trying to get the top grades and get into the top college and the top medical school and it's all about the performance and getting away from that to the extent possible and to really trying to see it as a learning opportunity is huge. [SPEAKER_00]: I think that's really important and has to be set from the top.

46:25 [SPEAKER_00]: And I would add that, oh, sorry, I'll go ahead. [SPEAKER_01]: Oh, sorry. [SPEAKER_01]: I was just going to say that I think that in medicine as well, we're trained to sort of think about individual performance and after action review, you're sort of training to think about how a system improves rather than the individual, the thing is a key distinction.

46:45 [SPEAKER_00]: Absolutely. [SPEAKER_00]: What were you going to say, Mike? [SPEAKER_02]: I was going to say first of all, Neil hit the nail on the head on several things and I think he just wrapped up one of the major things that I was going to say is that when we focus so much on your learning and what you're going to do and there's test questions about what you're going to do and you're going to respond it doesn't really accurately.

47:05 [SPEAKER_02]: develop the picture of how things will roll out in those situations, the importance of across different professionals, professions and specialties, right, how these things roll out. [SPEAKER_02]: The wonderful thing about an after-action, and we all do different ways in the military. [SPEAKER_02]: The air force does it a little bit different than the army, the language a little bit different, but those fundamental elements that you guys were talking about were the same.

47:27 [SPEAKER_02]: Incorporates everybody. [SPEAKER_02]: Incorporates the people flying you know the flight cruise line the helicopters the guys in the ground the J attacks the special operations Special operators everybody who's involved including people back in the operation center that are watching all this unfold on monitors having different perspectives across people who are seeing it very different ways [SPEAKER_02]: incredibly important.

47:48 [SPEAKER_02]: It also gets buying from everybody as part of this larger team. [SPEAKER_02]: It levels the playing field. [SPEAKER_02]: In fact, a lot of the times there are unspoken roles or cultural rules about how we conduct these in the military. [SPEAKER_02]: I even level the playing fields, whether you're a colonel or whether you're a specialist.

48:05 [SPEAKER_02]: whether you're whatever your rank is often leveled out for like an after action the same thing in the ICU or after a cold whether or after a cold one of if you're one of the medical texts if you're one of the nurses respiratory therapists residents, attendings, whatever everybody has to say and I think that.

48:23 [SPEAKER_02]: to get to your question earlier about why doesn't it happen while like in the military it's just it is in grain in the fabric of what we do every day all the time and part of its knowledge gap and different ice use part of its culture of medicine different attending different dresses residents rotating through every month.

48:42 [SPEAKER_02]: But in a large part, I think, because it hasn't been accepted quite yet as a cultural standard, which is accepted. [SPEAKER_02]: This is how we conduct business. [SPEAKER_02]: This is what we do after a difficult intubation, a difficult cannulation, a cardiac arrest, whatever. [SPEAKER_02]: When I think if we model that behavior, kind of like you were getting to in the 10 things, [SPEAKER_02]: and ingrained in our trainees and our nurses and respiratory therapists, if I forget at the Chargners or the Elite Nurse Foundation holds my feet to the fire and is like, wait, before you guys go, let's make sure we do the after action.

49:14 [SPEAKER_02]: That is the culture of a very good organization with a strong growth mindset that wants to prove after all these events. [SPEAKER_02]: And I think that's the critical part. [SPEAKER_01]: Yeah, absolutely. [SPEAKER_02]: Good, no, go ahead, no. [SPEAKER_01]: I just wanted to call up on something Mike said, definitely true that the Air Force and the Army do after action reviews differently, but I would argue the Army does them much better than the Air Force.

49:38 [UNKNOWN]: That's what we're talking about. [SPEAKER_00]: To Shae, well done. [SPEAKER_00]: Let's talk about mentorship. [SPEAKER_00]: Obviously there's different kinds of mentorship. [SPEAKER_00]: There's the kind of clinical skills mentorship of helping someone improve their clinical skills, their procedural skills, but there's other kinds as well.

49:51 [SPEAKER_00]: So what do you think is really important about mentorship and especially going beyond that technical mentorship? [SPEAKER_01]: Yeah, I was, you know, when I first came to medicine after the military, one thing I missed was with the mentorship and the military and just to talk a little bit about what that was like, it was an explicit model of mentorship.

50:14 [SPEAKER_01]: It was a formal one. [SPEAKER_01]: And so you had these scheduled periodic counseling sessions with your immediate senior, with your immediate senior. [SPEAKER_01]: You would have development plans. [SPEAKER_01]: There were someone who was always responsible and accountable for your professional growth.

50:32 [SPEAKER_01]: This is career-long development. [SPEAKER_01]: Your identity, your purpose, your goals, professional goals were a common topic of conversation. [SPEAKER_01]: And you know, I think we certainly do a really good job of procedural mentorship and in medicine, that's really a big part of what we do very well.

50:51 [SPEAKER_01]: What I think we do less well is this sort of idea of sponsorship, which is ensuring that [SPEAKER_01]: and trying to determine TAs and trying to people who are in the same career field as you have these opportunities. [SPEAKER_01]: We have these instances where we are episodically advocating for them.

51:10 [SPEAKER_01]: So that means putting their name forward for a specific opportunity. [SPEAKER_01]: This happened constantly in the military. [SPEAKER_01]: And I think part of the reason for that was because, you know, I remember one of the first interactions I ever had with my company commander wasn't these are my expectations and you better meet them.

51:28 [SPEAKER_01]: It was, you know, we had a couple of coffee together and we talked about what my goals were over the next couple of years. [SPEAKER_01]: You know, what were my leadership goals were my professional goals were. [SPEAKER_01]: over the course of the next year he gave him opportunities to really advocate for me when opportunities arose for me to enhance any of the things that I was really interested in in working on as a leader and and and as part of my professional development.

51:53 [SPEAKER_01]: This is something that I feel like the the medicine really leads to informal networks instead of these structured mentorship and sponsorship activities. [SPEAKER_00]: Yeah, absolutely great. [SPEAKER_00]: My name is anyone either. [SPEAKER_02]: No, I think that was it. [SPEAKER_02]: I think that that mentorship is just on on so many different levels.

52:12 [SPEAKER_02]: Like Neil said, like, big picture, macroscopically, where do you want to go and what do you want to do as well as like day in and day out like how things going, how are you progressing toward your goals, how is this rotation going for you? [SPEAKER_02]: like all of those things, I think are fundamental and building a really healthy culture and mentoring our trainees.

52:31 [SPEAKER_00]: Yeah, completely agree. [SPEAKER_00]: All right, we've covered so much great stuff. [SPEAKER_00]: Let's say one last thing, if you could each give one thing that the listeners should do differently tomorrow on their next shift in the ICU, what would you tell them? [SPEAKER_01]: I think, for me, something that's really, really easy to implement in your next shift at the in the ICU as a map capture review.

52:52 [SPEAKER_01]: And I think that actually includes so much of what we talked about because this is a way to learn from any sort of deficiency in your team dynamics. [SPEAKER_01]: It's a way to, you know, try to understand if there's any issues with the ways that you're communicating information, particularly during critical events.

53:09 [SPEAKER_01]: And it's a way to make sure that you are constantly leading a learning team. [SPEAKER_00]: Yep, totally fabulous, Mike. [SPEAKER_02]: Yeah, I would say if there's one thing moving forward, getting back toward a discussion about system one and system two thing maybe to analyze your practice and think about how you're approaching these problems, especially for those advanced trainees and tending who have had experience and exposure to this and begin to start to train our residents and fellows using that shadow boxing approach and how to recognize those things and apply and the structured and healthy, [SPEAKER_00]: Yeah.

53:49 [SPEAKER_00]: So many good lessons. [SPEAKER_00]: So highly encouraged people take some of this into your next shift, try it out. [SPEAKER_00]: This is stuff that's going to really make a difference. [SPEAKER_00]: Awesome. [SPEAKER_00]: Let's go to the last part of our show where we make random recommendations.

54:01 [SPEAKER_00]: What is something you would recommend the audience check out for fun. [SPEAKER_00]: Neil, we'll start with you. [SPEAKER_01]: Sure. [SPEAKER_01]: We have a one-year-old so we're constantly trying to figure out activities that [SPEAKER_01]: you know that make her really tired during the day so that she goes to sleep in a normal time night.

54:16 [SPEAKER_01]: But we had a really great time going to this place near Baltimore called Weber Farms. [SPEAKER_01]: It's a pumpkin patch. [SPEAKER_01]: We've got a bunch of cider and a bunch of pumpkins and really good food and a lot of activities. [SPEAKER_01]: I took our one-year-old on our first experience on [SPEAKER_00]: Yeah, second that we've taken our kids there and it's fabulous, a lot of fun.

54:43 [SPEAKER_00]: Mike, how about you? [SPEAKER_02]: Nice. [SPEAKER_02]: And it started slightly more nerdy recommendation after, you know, use it the kids and all, you know, transitioning at a fellowship. [SPEAKER_02]: I'm finally at a place where I'm reading books. [SPEAKER_02]: of interest again, not articles, books of interest, and actually one that just came across that I absolutely love is called Primal Intelligence.

55:04 [SPEAKER_02]: It actually deals a lot with this subject matter. [SPEAKER_02]: It's a fantastic read and touches on a lot of these topics that a much more deeper way and explains through the lens of special operations, how we think about some of these things. [SPEAKER_00]: very cool and I'm going to recommend a recipe that I discovered in the New York Times recipe app.

55:24 [SPEAKER_00]: It's for crispy noki with sausage in broccoli and I made it last night and it was fabulous and I'll tell you it is easy. [SPEAKER_00]: It is all you need is some store-bought noki sausage broccoli and [SPEAKER_00]: I'll have a few seasonings and that's it and it's on a sheet pan and the whole thing from start to finish probably takes about 30 40 minutes and it is fabulous.

55:43 [SPEAKER_00]: The whole family loved it and it's really delicious. [SPEAKER_00]: So check out that recipe. [SPEAKER_00]: We'll put it in the show notes as well as links to your all recommendations. [SPEAKER_00]: Neil and Mike. [SPEAKER_00]: Thank you so much. [SPEAKER_00]: This has been great. [SPEAKER_00]: I learned a ton and I know our listeners will too.

55:55 [SPEAKER_00]: Thanks for coming on the show. [SPEAKER_02]: Thank you so much for having us. [SPEAKER_02]: And no problem. [SPEAKER_02]: Pleasure to be here again. [SPEAKER_02]: Thanks for having us. [SPEAKER_00]: All right, hopefully you got as much out of that as I did. [SPEAKER_00]: That was really fantastic.

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57:10 [SPEAKER_00]: Sonia Aminat is our tech lead, Chitima Econty, Rachel Furman, and Muhammad Selab are our production assistants and social media managers. [SPEAKER_00]: Thanks so much for all you do. [SPEAKER_00]: Our original ACRAG music is by Dr. Dennis Quow. [SPEAKER_00]: You can check out his website at studymusicproject.com.

57:27 [SPEAKER_00]: All right, that is it for today. [SPEAKER_00]: For the ACRAG podcast, I'm Jed Wolpa. [SPEAKER_00]: Thanks for listening. [SPEAKER_00]: Remember what you're doing out there every day is really important and valued.