After my recent Resus Room Readiness post, my buddy James got in touch with me wanting to do this episode. I said frack that, we can't do an episode, there is too much goodness in the French brain, we need a series. This is the first episode in a new series with an amazing Emergency Medicine Doc and Innovator, James French.
James French, MD
Dr. James French was born to a father that was an incredible engineer and tenacious inventor. James’ earliest memories were working with his dad restoring vintage motorcycles which sparked his fascination with fixing things. When James was 5 years old he went to watch the film “Superman” with his dad. It turned out they knew Christopher Reeves from the flying club that they went to, so they actually knew superman while he was learning to fly. James attended many Emergency Departments in the years after as it turns out that no matter how hard he believe you can fly or whatever machine he invented, gravity always won.
Whilst studying for a science degree he realised that training in martial arts was a partial antidote to not being able to sit still or focus on one task and has trained in martial arts throughout the majority of his life.
In 1995 James started medical school in Southampton, England. In 1997 at a local kung-fu club he met a guy called Dr. Cliff Reid who was a resident or registrar in Emergency Medicine. They immediately became friends. Whilst at medical school James would shadow Dr. Reid when he worked in the ED, particularly at weekends . They constantly exchanged ideas about resuscitation, psychology, meditation and of course martial arts. Cliff later stated openly on social media that James saved him from a residency system that was breaking him. To outsiders it was obvious that the “saving” was a two way street. James’ passion for resuscitation and education comes from Cliff.
James graduated medical school in 1999. Whilst driving to work as an intern in 2000 he was first on scene at a fatal road traffic collision. Trying to render aid to multiple trapped and dying casualties, with no formal training in prehospital care was a formative experience. He started working with the Magpas Air Ambulance System (www.magpas.org.uk) as a volunteer in 2003. The training course featured multiple days of simulation based medical education, a competency based curriculum and was probably a decade ahead of its time and was lead by the legend that is Dr. Rod Mackenzie. Influenced heavily by the aviation industry and the military Rod and James invented the first RSI kit dump and RSI checklist in about 2006. James continued to work with Magpas in PHEM until 2012.
In 2009 James started working as an attending in Addenbrookes Hospital, Cambridge and was given the task of selecting and purchasing all of the clinical equipment and for a new Trauma Center. Influenced heavily by a very strong department of clinical engineers lead by Prof Paul White, James realised the necessity of applying principles of from EMS, ergonomics, lean and clinical engineering to resuscitation practice.
In 2012 James moved to Canada to work in Saint John, New Brunswick. Whilst in New Brunswick he chaired the trauma research subcommittee and lead an interprofessional team to establish a province wide simulation system for trauma education. In 2017 James met Dr. David Elias, who is an Emergency Physician and highly successful medical entrepreneur, whilst competing for simulation equipment at Medical Lion’s Den competition. James started working with Dr. Elias and his healthcare innovations company in 2018. James describes Dr. Elias as the “Elon Musk of medicine” and is without doubt the smartest guy he has ever met.
Currently James works as an Emergency Physician and in Saint John Regional Hospital, and is the lead for Operations Design and disaster management. He is a faculty member of the simulation and ultrasound group in the department of emergency medicine. James is the co-owner of a growing Medical Education and medical retail company with the uber keen ACP, George Scott (www.aemts.ca) . He also works in applied R&D with Dr. David Elias for Canadian Health Solutions in cognitive technologies.
Intro for the Series from James:
INNOVATE OR DIE
“If I had asked the public what they wanted, they would have said a faster horse”
–Henry Ford (1863 – 1947), Founder of Ford Motor Company
A physician called Dr. Frank Pantridge, the godfather of Emergency Medicine, working with NASA engineers in the 1957, using telemetry equipment designed for space vehicle monitoring discovered Ventricular Fibrillation was the arresting rhythm in a large proportion of out of hospital cardiac arrests. Using capacitors from NASA, he also developed the first portable defibrillator. Then EMS and ACLS happened (albeit 40 years later). He had no formal training in design or electronics. He was by all accounts incredibly driven to understand how he could resuscitate people, which for Dr. Pantridge was personally relevant. He developed cardiac Beri Beri after starving as a POW working on the Burma Railway and lived most of his life knowing his heart would fail.
What a total badass. Other notable medical innovators in our history are Sir Ivan Whiteside Magill and Sir Robert Macintosh – guess what they invented?
Innovation is part of our history – we need to make sure it is part of our future.
Creativity is conceiving new ideas. Innovation is turning those ideas into a solution. Medical research in a traditional sense is testing the solution to see if it works. Medical academia is currently some form of education or some form of medical research. That is what we get tenured for. That is what you can publish and get grants for. We have universities that support this activity, and that is utterly essential.
However what structures exist to energize the creativity and innovation in frontline healthcare workers? In my experience very few.
Nobody would argue with the importance of performing high quality research. It seems a significant part of what we do now is debunking many of the things we have accepted as dogma which was often based on the poorest quality research. Performing research according to STROBE, CONSORT and the like is clearly beneficial for everyone, but I worry that the uniformity needed to get published and get grants has created an environment that may stifle innovation.
Right now, I think, most of our patients don’t need another randomised control trial. What is becoming increasingly obvious is they need to be able to access equitable healthcare whether they have hypertension or septic shock. They need to be able to access healthcare regardless of their background or geography. We know unequivocally that unfortunately this is not the case.
As Friedrich Nietzsche wrote “A vocation is the backbone of life”. The vocations that drive us, or the “why” hasn’t really changed in healthcare. The “why” is we want, or need, to provide the best possible care for people. The “what” has changed at an exponential rate however; the “what” being increasing case comorbidity, the number and complexity of treatments, and which tests to perform and how to interpret them. The know-do-gap, which is the difference between what is known in the literature and what is actually delivered to patients is rapidly increasing. (Webber, S., 2015).
The “how” in this equation is how we are educated and do our jobs which really hasn’t changed that much in the last 50 years. There have neen significant and notable improvements, but remove EHRs, bedside ultrasound, simulation, social media and online learning and I am told that the way we learn and work looks very similar to how it was before I was born.
So, this is my frame, just so you know. I find it harder and harder to keep up to date. I see my colleagues burning out. We all see older people waiting longer to have ever more complex cases managed. l see people suffering, needlessly, and it each time I see it I am driven more to find the best formula to “fix it”. I definitely do not have all the answers, but there are things that we can learn from other industries that can go a long way to filling the gap.
If we think, as a profession we are going to achieve health equity, using our current medical paradigm, or by just stretching the existing system further than we already have, then we and our patients are only going to continue to suffer
We need to do things differently. We need to innovate.
JF
So there you go…
Today, in Part 1, we discuss a topic near & dear to my heart:
Part I – Resus Geography, Logistics, & Ergonomics
The need for these approaches in resuscitation and critical care
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- Talk about a cric case i did where there was nearly 200% mortality
- Millers Law (The average person can only keep 7 (plus or minus 2) items in their working memory) – Loss of PPE.
- Hicks Snail Trail
- Talk about a cric case i did where there was nearly 200% mortality
Resuscitation ergonomics
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- Lean Methodology – What plays together stays together
- Process mapping, swim lane, how to do it.
- GOPRO video skills training
- Pen. Eyeball,Post It notes
- Who does each stage?
- Work as imagined vs. Work as Done – what you think you need is not what you actually need. We eliminate steps when our mental simulator is low resolution when we have move to unconscious competence.
- Break Need Items into Packs (Hicks' law – every extra thing added to a visual field leads to exponentially increased complexity)
- Can be broken down by…
- by color-yellow = ppe
- by user green for go, “own shit kit”
- by stage- everything else in another bag, blue
- Can be broken down by…
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Resuscitation Geography
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- Hospital design
- 1 entrance/exit for various streams (patient, staff, logistics)
- Immediate Items vs. Just Outside vs. Further Away
- COVID made us think about these issues
- Staging – ECMO example. Jason McCLure
- Geography by Stage
- Hospital design
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Logistics
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- Getting it to the user
- Getting it to the warehouse
- Nominative vs functional checking
- Checking each other—is it there vs. is it there and can we use it
- Currency and refresher system
- Changing case mix
- Increasing less emergent demand
- rural vs urban level 1, 2, 3.
- The patients chest and the bedside table.
- innovation vs. optimization. In healthcare, we often concentrate on the former at the expense of the latter
Additional Information
Discussion Topics
- Mastery Learning10,11. Competency is the first stage of mastery and can be achieved by Deliberate practice12, with Over Training13 a beneficial side effect which decreases skill fade.
- In Situ Simulation14-19 and Transitions Training. Competency must be adapted to suit the specific operational environment. Processes must be tested that cross professional and geographical boundaries.
- Clinician Focused Performance Assessment and Professional Development. Each nurse, doctor and paramedic should have a personalized learning package that compliments their pre-existing training and exposure, knowledge, skill and behaviour.
- Clinical Ergonomics. Principals from Lean Six Sigma20 and Ergonomics21 are being applied to equipment storage, layout and labelling that mirrors the clinical task.
- Procedural Checklists and emergency action checklists22-27. Checklists improve safety, but used incorrectly are ineffective or can cause harm.
- Refresher Tasks. Over time, skills will fade28,29. Interval recall testing enhances retention30 of important information and skills 13,30.
References for Today's Conversation
- Parachute. The Cost of Injury in Canada. Toronto. 2015.
- Peden M, McGee K, Krug E. Injury: A Leading Cause of the Global Burden of Disease. World Health Organisation. Geneva; 2000.
- Luckanovic D, French J. Exposure to Major Trauma Management of Learners Training to Become Emergency Physicians in New Brunswick. Trauma Association of Canada 2014 (Poster).
- Gruen, RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of Errors Contributing to Trauma Mortality. Annals of Surgery. 2006;244(3): 371-380
- Cook T, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia. 2011;106(5): 632-642.
- Green RS, Edwards J, Evaluation of the incidence, risk factors, and impact on patient outcomes of post intubation hemodynamic instability. Canadian Journal of Emergency Medicine 2012;14(2):74-8
- Brown CA, Blair AE, Palin DJ, Walls RM. Techniques, Success, and Adverse Events of Emergency Department Adult Intubations. Annals of Emergency Medicine. 2014;10(36):110-114
- Menger R, Telford G, Kim P, Bergey MR, Forman J, Sarani B, Pascual J, Reilly P, Schwab CW, Sims CA. Complications following thoracic trauma managed with tube thoracostomy. Injury. 2012;43(1):46-50.
- McGee DC, Gould MK, Preventing Complications of Central Venous Catheterisation. N Engl J Med. 2003; 348: 1123
- Greene R. Mastery. Viking. (BOOK) ISBN 0670024961.(2012)
- Guskey TR. Mastery Learning in 21st Century education: A reference handbook, vol 1 ed. Good TL. California: Sage Publications.(2009)
- Ericsson A, Krampe RT, Tesch-Romer C. The Role of Deliberate Practice in the Acquisition of Expert Performance. Psychological Review 1993, Vol. 100.
- Weiss MW. “The Effects of Overtraining on Updating of Human Episodic Memory.” University of Arizona (Book) (2010).
- Passiment M H, Sacks G. Medical Simulation in Medical Education: Results of an AAMC Survey.[Survey] Retrieved from https://www.aamc.org/download/259760/data (2011).
- Figueroa MI, Sepanski R, Goldberg SP, Shah S. Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular intensive care unit multidisciplinary team using simulation-based team training. Pediatr Cardiol. 34(3), 612-619 (2013).
- J.M. Weller. Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ. 38(1), 32-38 (2004).
- McCaghie W et al. Does Simulation-based Medical Education with Deliberate Practice Yield Better Results than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence. Acad Med. 2011; 86(6): 706–711.
- Improving patient safety through simulation research. Agency for Healthcare Research and Quality. Available at: grants.nih.gov/grants/guide/rfafiles/RFA-HS-06-030.html.
- Rosen MA, Salas E, Wilson KA, King HB, Measuring Team Performance in Simulation-Based Training: Adopting Best Practices for Healthcare. Simulation in Healthcare. 2008;3(1):33-41
- Krafcik JF. (1988). “Triumph of the lean production system”. Sloan Management Review30(1): 41–52.
- Sharples S, Shorrock S. Contemporary Ergonomics and Human Factors. Institute of Ergonomics and Human Factors. Taylor Francis (Book) (2014)
- Sherren PB, Tricklebank S, Glover G. Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill. Scand J Trauma Resusc Emerg Med. (22) 41 (2014).
- Mackenzie R, French J, Lewis S, Steel A. A pre-hospital emergency anaesthesia pre-procedure checklist. Scand J Trauma Resusc Emerg Med. 17(Suppl 3) (2009)
- Kerry B et al. Improving the Safety of Rapid Sequence Intubation in a Pediatric Emergency Department. Ann Emerg Med. 62(4) S22-S23 (2013).
- Babolhavaeji F, Rees I, Maloney D, Walker J, Knights M. Checklist for emergency induction of anaesthesia in critical care. Anaesthesia. 68(6), 661-661 (2013).
- Smith K, High K, Collins S, Self W. A preprocedural checklist improves the safety of emergency department intubation of trauma patients. Acad Emerg Med. 22(8), 989-92, (2015).
- Thomassen Ø, Storesund A, Søfteland E, Brattebø G. The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand. 58(1), 5-18 (2014)
- Konrad C, Guido S. Learning Manual Skills in Anesthesiology: Is there a Recommended Number of Cases for Anesthetic Procedures? Anesthesia and Analgesia. 1998; 86(3): 635-639
- Ali J. Attrition of Cognitive and Trauma Management Skills after the Advanced Trauma Life Support (ATLS) Course. Journal of Trauma. 1996;40(6):860-866.
- Brown PC, Reedier HL, McDaniel MA. Making it Stick: The Science of Successful Learning. Belknap Press (Book) 2014.
James French writes his thoughts after the completion of the Podcast
I thought I should summarize my thoughts regarding our podcast.
Essentially I was given the task about a year ago of choosing, procuring and embedding all the new clinical equipment and associated procedures for use in our new emergency room. You may recall that UK trauma systems have been extensively reformed (finally – Injury; the Epidemic of Modern Society published in 1966 I believe). Our hospital has been designated as a trauma centre which required significant redevelopment. This was a fantastic opportunity, a blank canvas, that I wanted to be a an organized process diagram rather than a Jackson Pollock!
I started wondering why I found it easier to manage a seriously injured trauma patient in the Prehospital phase, which is a resource limited, time pressured, safety critical and sometimes hazardous operational environment, than in a resuscitation bay. I think some of the features that make such PHEM scenarios “slick” are as follows:
1. The practitioners are relatively senior.
2. All of the practitioners are educated using a competency based curriculum, delivered using full immersion simulator based training. They therefore are competent, but also their competency is context specific.
3. The equipment used is packaged logically in sections, so “what plays together stays together”.
4. Each equipment section for example in a Thomas Pack, is mainly kitted for a single procedure on a single patient. Once the bag is “trashed” it is labelled not safe to use and is restocked. The response platform therefore contains additional complete trauma bags, which can be used immediately in other patients.
5. Where necessary our practice is supported by a procedural aide memoir (PAM); a simple, accessible, process driven document that helps us do the procedure.
6. And you know your kit backwards, because you've packed it a thousand times!
7. You also usually only have one or two patients to deal with at a time.
8. Care is transitional. We transition from the car wreck to our trolley, we then stabilise, splint, anaesthetise and package, and then transition to the transport platform where we transition to the receiving hospital. We don't notice these transitions, because that's our job, and we don't see being mobile as abnormal. In fact PHEM practitioners get uncomfortable when we stay in one place for too long.
9. On the roadside space is not a problem! (usually, well unless you're trapped, well you know what I mean!)
Let's just contrast that to the reality of a busy Emergency Department:
- There are more juniors than seniors. And supervising doctors are frequently tied up looking after one of the fifty other patients.
- The practitioners may be competent, in terms of strategy, for example they've been taught to put in a chest drain and have done ATLS, but it is highly unlikely they will have context specific competency to your individual ER operational environment. Their induction will have covered fire lectures, infection control, and where to take a dump, but actually sweet naff all when it comes to actually looking after a crashing patient in your totally individual operational environment. More than that no two trauma teams are ever the same. Add into that three new intakes of doctors per year and residency rotations And the only safe and logical thing to assume is that although they may know what to do (strategy) they may have little or no idea how to actually deliver this competency in your operational environment (clinical logistics).
- Equipment is often scattered, seemingly at random, all over your department. I'm sure we can all recall taking longer to find the right bits of kit, than it actually takes to do the procedure. This time is wasted and one thing none of us have is time to waste in a busy ED. A manager that practices using lean management principles would call this “non value adding time”; I call it, exasperating, frustrating and a total ball ache.
- Because each bay is used continuously ,often you have no idea which bay is safe, what resources you have, and the redundancy is in a store room, down the corridor, usually near the toilets or the staff room.
- We have policies and sops, usually more than we are aware of, but these are often relatively inaccessible and too long to actually support practice in real time.
- Doctors in an ED seldom contribute to equipment checking and stocking. Why? Because we have 300-600 patients a day, and we don't have enough resources to look after them, let alone do a job that could be done by a nursing aide. Some docs will also believe that such activities are beneath them.
- We have departments bursting at the seems with patients, surging excessive inflow, exit block and resulting overcrowding.
- Care in an ED is seldom considered to be transitional. It's all about the resus moulage, or the procedure, etc etc. We don't routinely drill, analyse or refine our transitions to CT, theatre, and IR. however how many times have you been on even a short transfer, in the hospital, and the monitor has failed, or the infusion pump battery has gone dead, or you've dropped a highly expensive item of equipment ? Think about the courses we do ATLS, APLS; none of these courses consider these transitions, however you could argue that a patient is at more risk when transitioning between healthcare geography in a hospital than at any other time during their journey.
So how do we manage these risks, and try to emulate our PHEM practice? Well given we are all almost by definition pragmatists in EM let's consider the following example. Mr Smith needs a chest drain.
- Everything you need for a chest drain insertion is on one place. All major procedures are stored in single use trays that contains everything you need. These trays are stored in mobile equipment stacks that can be wheeled if necessary from on bay to another. There is a separate stack for medicine, trauma and Paeds. This makes each bay completely patient adaptable. You dept have to hunt around for anything. This is truly lean and efficient.
- The chest drain procedure tray contains in its base an A3 PAM that helps you decide on drain sizes in kids, the volume of lidocaine you need by age/mass band, a simple how to guide and team support information (how to get hold of senior support in a hurry).
- The tray slots into a generic procedure trolley. The procedure trolley contains any items you may need that are not in the procedure tray that are individual to the user, for example sterile gloves. each tray also contains the relevant paperwork you need to fill in.
- The trays are labelled with high levels of conspicuity. You can identify a tray from 12 feet away.
- Once used, the tray is transferred to a used rack. Each morning the trays are barcode scanned, which tells me about frequency of procedure use (and infers the currency of our users), updates our stock requirements, and tells our clinical logistics team what trays they need to make that day. Because stock control is so closely monitored and uses a pull system, or Kanban system, we need less space for storing disposables. We don't rely on massive stock in out department, rather a rapid logistics chain. This means, in theory at least, you could turn some of your many stick areas into clinical areas (if your logistic chain is up to it).
- Each bay has a medical and trauma tower and we have two Paeds towers. They are all identical. This results in massive shop floor redundancy.
- The only elements of the systems that are not single use are the airway trolleys. These are checked every day using two person challenge response checklists. The docs also do this. To maintain awareness we also do rolling functional checking. For example Thursday might be chest drain day. The daily diary will read ” Daily functional check. Using a PAM talk though chest drain insertion and lay out the circuit necessary using the silhouette.” Checking is therefore an educational functional activity, rather than a nominative one.
- We have started the Transitions Project. Each transitions team guides rapid, safe and effective transitions and is composed of staff members that are involved in each interface. For example the CT transitions group contains ED and Radiology staff. This work is ongoing but I will keep you posted regarding the results.
Procedural Tacit Knowledge
- For procedures we use a micro skills from swim lane process mapping approach incorporated with RCDP.
- Engineering Approach to Procedural Steps
- Medicolegal Causal Analysis
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James, wonderful to read and hear your work getting the attention it deserves. Need some picks of your successful fishing career to compliment your other great successes.
Thanks man!
Great podcast & discussion James – but how do I apply this theory to keeping my ultrasound machines clean and fully charged? 😉
Great listen! First of all, I am a big fan of the podcast. Secondly, Dr. Weingart, I love that you had the self-awareness to stop the podcast and say what you did. Dr. French, thanks for sharing your knowledge and acting so graciously in the interview. I really enjoyed the dialogue between the two of you!
lads, just finished the ‘cast. great work to you both, i am precisely the 1% of listeners who cares about just-in-time stocking, or lack thereof. you both handled it all masterfully as always. re: infinite bundles. scott, point taken on the trade off between efficiency of bundles vs. inefficiency of bundle creation. i grappled with just such a question creating the resus towers. scott, the problem (in our shop at least) with the run and grab it after approach is that it’s never #*$^&ing where you want it, and even the search for non-critical accessories (sutures, gauze, etc) can be… Read more »
fantastic!!
I am so pleased that this is getting the attention it deserves. In a world where we seem obsessed with ‘wellbeing’ at one end and interventions like REBOA at the other, I truly believe that the actual way to make a difference is to pay attention to the simple stuff: like having equipment to hand when you need it. If I was to construct a “Maslow’s Hierarchy of Good Emergency Care” being able to have the right equipment, that is easy to find and in the right place, would be just above “access to toilets and food”. That this is… Read more »
so glad to hear from you Iain!!!