The ability to simplify means to eliminate the unnecessary so that the necessary may speak –Hans Hofmann

We live in complex times.  Resuscitation has gone endovascular, microvascular, mitochondrial.  EPR, ED-ECMO, REBOA–it’s a fascinating time to be a Resuscitationist.  But the more we advance the resuscitation agenda, the more we learn how complex critical illness can be.  And with that comes the need to simplify complex problems, so we can think clearly and implement sophisticated, maximally-aggressive care when the moment arises.  Because when situations get really complicated, it is precisely our ability to simplify and organize our approach that will see us through.

Complex is Different

Complexity isn’t just more of something, it’s different – highly complex systems respond and behave according to a different set of rules than their simpler counterparts, due in part to random, chaotic and unpredictable events, and the interaction of individual elements within a larger entity. < 1 > Anyone who has been challenged with managed severe sepsis is familiar with this reality.

Changing the scale means changing the rules.  Consider the googol:

10¹⁰⁰

A googol is a gigantic number, but despite the fact that it’s huge, it’s not all that complex.  Kolmogorov Complexity, an element of Algorithmic Information Theory, defines the complexity of an entity as the minimum number of bits of data needed to describe that thing, without losing information. < 2 > Accordingly, a googol is much less complex than this:

499 001 599

A nine-digit prime number is more complex because it can’t be factored down any further from its surface complexity.

Your Next Patient

A 22-year-old female, unbelted driver in a motor vehicle collision at high speeds is partially ejected through the windshield.  This ends up saving her life, because prior to extrication the vehicle bursts into flames.  She arrives at your hospital hemodynamically unstable, with a bad facial smash injury, burns about her head, neck and torso, a presumed left flail chest, a mechanically unstable pelvis – and when you ultrasound her abdomen you realize she is probably somewhere in the early part of the third trimester of pregnancy.

You can practically hear the sphincters slamming shut when a trauma case like that rolls in.

Managing Complexity

There is a fascinating convergence in philosophy, design, ecology, mathematics, engineering on the importance of simplifying complex problems to make them more accessible and manageable.  Steve Jobs said that simple can be harder than complex, because you have to get your thinking straight first.  If you want “Keep It Simple” to be more than just a platitude, you need focused strategies to manage complex situations when they arise – a pick-list of cognitive and behavioural hacks to help you get with the science of simplicity.

Remarkably, managing complexity can be achieved with a series of surprisingly simple tools.

Here’s what we’ll cover:

• The power of habit and routines
• How to harness emergent order within teams
• Strategies for factoring down complex problems
• Constraining chaos, or how to limit variables

1. Habit

“First we make our habits, then our habits make us” –Charles Nobel

Habits – both good and bad – have a lot to do with whether we succeed or fail.  A well-formed habit can simplify a difficult scenario by breaking it down into smaller, rehearsed steps.  What’s interesting is that once sufficiently rehearsed, it becomes more difficulty to not execute a habit than it is to execute it. < 3 > The key element is the ability to recognizing environmental cues that trigger a habit or routine, so becomes a reliable part of your approach.

Habits differ from goals, which tend to over-emphasize the endpoint in a process without considering the more elemental steps that will lead you there.  I could tell myself that I want to learn all three of the Gershwin piano preludes in the next six months (a goal), or I could make it my habit to practice piano for twenty minutes every day.  The latter is much more likely to get me to my goal.  Similarly, you may look at our trauma patients and tell yourself you want to save both of their lives (a goal), or you can make it your habit to approach a hypotensive blunt trauma victim in the same way each time, so that you don’t overlook the important stuff by investing too much mental energy trying to make sense of rare or atypical features.

The concept of habit and routines is a core concept in the science of performance and preparation in high-stakes domains like elite athletics.  Preparation for athletes focuses on process rather than outcome, and establishing consistent habits and routines – this strategy not only helps to manage complexity, but helps put athletes at a better position on the performance-arousal curve, so they can execute more effectively when the time comes.

This may sound like I’m endorsing an overly rigid approach, but I believe the opposite is true.  Situation awareness is a relative concept – In order to effectively navigate at sea, you need to understand your own position before you can start to take appraisal of objects and cues around you and set a direction.  Having a standard approach, habit or routine in response to a challenging situation puts you and your team in a better position to detect variance, anomalies and atypical features that are so vexingly common (but often difficult to detect) in complex scenarios.  Accounting for the typical by way of habit enhances your cognitive bandwidth, amplifying your ability to account for and manage complexity that lies outside the boundaries of routine behaviour.

For more on habits versus goals, check out this awesome post from the Farnam Street blog.

Back to the case: I would take my team through my standard approach to a hypotensive trauma patient, a habit I have rehearsed and executed countless numbers of times before, without making any major variances based on the presence of a baby, or burns.  In so doing, I can ensure we don’t miss any major critical injuries during our primary survey.

2. Emergence

Once you’ve accounted for the routine, it’s time to harness the power of emergent organization.  Emergence itself is a complex idea that has gained popularity as a strategy to manage complexity of business and global markets.  What it refers to is a process of self-organization by which individual simplicity can generate organized complexity – simple agents, acting according to simple rules, organizing into sophisticated systems with the ability to solve complex problems.  < 4 > Put simply, this is why the whole can be greater than the sum of its parts, and helps to explain why high performance teams can so enhance the competencies of its component team members.

Emergent organization is seen in a variety of biological, social and engineered systems.  It’s believed to be the underpinning for how ants can organize to hunt down your picnic basket, or even how neurons can assemble to create intelligent neural networks.

Perhaps the most dramatic example of emergence can be seen in how starlings organize in flocks to create complex patterns of movement that is well in excess of the sophistication if its individual components.  If you tried to model starling flocks using a computer algorithm you would invariably lose accuracy over time – it is impossible to account for all of the individual variables that feed into that complexity of group behaviour.

Another way to approach the problem would be to simply try and define a few simple rules for how the individual elements of the larger system are meant to interact with one another, and let the complexity emerge from that.  For example:

1. Fly in the same direction as other birds in your cone of vision
2. Don't collide with other birds
3. Stay close enough to one another such that you are protected from predators

When you apply these rules, you get this:

https://www.youtube.com/watch?v=V4f_1_r80RY&t=30s

Remarkable complexity emerges from simple components operating according to simple rules.

Leveraging emergent order has implications for how you choose to set up your team to respond to a complex event.  This is your standard trauma team set-up, in functional arrangement:

During periods of high task load and decision overhead, it may make sense to re-arrange your team along more divisional lines, creating sub-teams or mini-teams: semi-autonomous units aligned with a specific delegated task.

The role of the team leader in this set-up is to foster emergent order without trying to over-engineer it – to create conditions by which team members can work together towards concrete, manageable tasks.

Back to the case: As team leader I would designate an airway team and a chest tube team, discuss the general parameters by which they would operate, agree on endpoints and back-up behaviour, and then allow those sub-teams to work semi-autonomously until the task was complete or a problem arose.  This allows me to focus less on operational and more on executive elements of a complex resuscitation.

3. Factoring Down

Glance at the following series of numbers for a fraction of a second and see if you can do the math (no cheating):

-1 + 4 – 9 – 4 + 7 + 3

Did you get it?  No you didn’t.  Try again:

+ 10 – 10

Better?  Problem 2 is just Problem 1 factored down and rearranged somewhat so that it is more accessible to your working memory given the time allotted:

(7 + 3) = + 10

(-1 – 9) = – 10

+ 4 – 4 = 0

When it comes to problem-solving, our minds are hard-wired to respond to complexity in one of two ways: either we do a deep dive into features of a problem that are familiar to us, which leads to fixation and premature closure, or we try and take the problem in all at once, which we can’t do, so we apply short cuts and heurists that often lead to errors in diagnostic reasoning.

Good team leaders recognize this, and the importance of factoring down a complex problem a level or two from its surface complexity.  This is different than breaking a problem all the way down into its elemental bits, which promotes micro-management; Rather, factoring a problem down a level or two from surface complexity will generally allow you to consider the majority of relevant variables in a given problem and then allow you to identify one or two areas of common concern that can be made priorities for your team.

A good example of factoring down is the ability to “bottom line” a problem.  This was made popular by NASA as a technique to simplify complex issues and create actionable problem lists.  The ability to succinctly summarize a problem is a useful tool in any situation where it is important to influence the thinking of others.  This comes up often in Emergency Medicine, where the ability to bottom line a patient presentation in one or two sentences over the phone to a groggy consultant at 03:00h is critical to ensuring that they can quickly come to appreciate your perspective.

Back to the case: You could bottom line this trauma patient’s presentation by saying “Okay, right now our patient has an airway problem and a circulation problem” – once everyone is on the same page, you can effectively put your team to work on addressing those priorities.

4. Limiting Variables

You can’t predict the unpredictable, but you can constrain chaos by limiting the number of paths a particular series of events can follow.  In so doing, you improve your predictive capacity, even during ambiguous or uncertain events.  The idea is to get you and your team from Point A to Point B in a process, task or procedure with as few surprises as possible along the way.

There is a multitude of ways to accomplish this, including:

1. Limit Task Variables: Can you actually run through a procedure from start to finish in your practice environment? This differs from simply being able to describe what you in words or on paper and focuses on how a task gets accomplished – the logistics, rather than the strategy.  Practically speaking, choose four or five procedures or processes that you view as complex, and the next time you’re at work see if you can actually work through all of the steps in real time.  In-situ simulation is a fantastic tool for working through complex tasks to identify the “unknown unknowns”. More on logistics vs. strategy here
2. Limit Steps: Does your massive transfusion protocol really need 7 steps before it can be activated? Does your thoracotomy tray have a bunch of tools on it that are rarely if ever used?  Limiting steps is in part a reminder that clinicians need to be involved in environmental, process and equipment design – we are not systems engineers, but we do have the best understanding of how design can be modified to fit a given clinical function.
3. Limit People: This is an unpopular opinion, but most teams are too big. Is everyone on your team really contributing, or are they just adding to complexity by creating noise and distraction?  If so, have a low threshold for giving idle hands specific tasks (to foster emergence), or clear the room of all non-essential personnel.
4. Know Your Team: In contemporary institutions, the burden of administrative duties often means that leaders are too far removed from the people and the teams they are supposed to be leading. Yves Morieux makes this point eloquently when discussing strategies to get your team to solve problems with you, or “increase the total quantity of power” within a team. < 5 > Next time you take part in an inter-professional simulation exercise, make sure you are devoting at least some time to better understanding your team member’s abilities, strengths and limitations.  This will help you limit the variable of knowing who is capable of what during a complex event, and plan back-up behaviour accordingly.  This also promotes team member engagement, which is a fantastic way to enhance the team-based problem solving that inter-professionalism is meant to facilitate.

Back to the Case:

Eventually, the scenario evolved into a “Can’t Intubate, Can’t Oxygenate” airway challenge.  Fortunately for us, we had invested the time in an iterative, simulation-based project to develop a streamlined bougie-assisted cricothyrotomoy kit that was hanging about two feet from the patient’s head.  The kit has a minimal amount of equipment and requires a minimal number of steps, all of which had been previously rehearsed during inter-professional in-situ simulation exercises.  Consequently, when it came time to perform a surgical airway on our trauma patient, it was about as calm and controlled a process as could be expected given the circumstances.

The summary slide:

The Bottom Line

There’s nothing simple about complexity, but the solutions to complex problems can often be surprisingly simple.  Much of what is discussed here relates to where you choose to place your effort when it comes to tackling complex problems.  Ask yourself: would you rather try to reign in chaos once it has already happened, or take steps in advance to keep you and your team in control?  The up-front investment in planning for and managing complexity will pay massive dividends the next time you step in front of the wire.

Want to read more?

Steven Johnson’s book “Emergence: The Connected Lives of Ants, Brains, Cities and Software” is a fascinating deep dive into emergence theory.

References

1. http://www.businessinsider.com/how-to-manage-complexity-2013-6
2. http://www.digitaltonto.com/2011/the-simple-dilemma/
3. https://www.farnamstreetblog.com/2017/06/habits-vs-goals/
4. https://www.forbes.com/sites/lbsbusinessstrategyreview/2013/11/28/managing-complexity-the-battle-between-emergence-and-entropy/#59a1e1b55936
5. https://hbr.org/video/4569031593001/six-simple-rules-for-managing-complexity

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Chris Hicks

I am an emergency physician and trauma team leader at St. Michael's Hospital, and Clinician-Educator in the Department of Medicine at the University of Toronto. I use simulation to help make people, teams and systems work better and more safely.

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