Slow is smooth, Smooth is fast but too slow is dead)

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Slow is smooth, smooth is fast

Special forces push this concept when training for urban combat.  When we work too quickly we risk making mistakes that  lead to harm.  This is especially true in high stakes but time sensitive situations (battlefield or resuscitation bay).

 

Slow is smooth, but too slow is dead

In contrast, in both the battlefield  and resuscitation bay working too slow can lead to people dying (or suffering permanent harm).  Slow is a relative term and  delays can be the result of a variety of factors including inefficiencies in our teams, failures of our systems or uncertainty in our thought process (paralysis by analysis).

 

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In pediatric resuscitation our most time-sensitive and critical events are exceedingly low in frequency.  Even in the busiest pediatric trauma centers a life saving intervention such as an ED thoracotomy is a rare event.  At the recent pediatric trauma society meeting I was awed by a case presentation of a patient who had a traumatic arrest with an unbelievable outcome.

 

The efficiency and effectiveness of the team in this time critical situation was not by an “accident”. This patient survived because this centers hard work to create a robust trauma system that includes highly trained providers.

As a northeaster for life I am not a NASCAR fan, however during the meeting someone showed the following video comparing trauma care to a pit stop.  This video gets at the point that no matter how skilled we are we need the right tools AND the right people.

Right people:  Those of us who work in academic centers need to recognize our responsibility to train community ED physicians who will care for 9/10 of severely ill and injured patients.  With decreasing time in pediatrics during residency and reduced exposure to critically ill children many of us leverage simulation-based instructional design to provide this training.

In our simulations and debriefings I have started to help trainees recognize their two modes of thinking that have been described by Nobel Laurette Daniel Kahneman:

  • System 1: Fast, automatic, frequent, emotional, stereotypic, subconscious
  • System 2: Slow, effortful, infrequent, logical, calculating, conscious

The challenge of time sensitive cases in pediatric trauma care is balancing our use of system 1 vs system 2 to be SMOOTH, fast and slow (with experience and practice my role models have developed a unique ability to use system 1 heuristics while concurrently using system 2).

However an additional challenge that I have always recognized is the over-confidence that can be found in some of our trainees and colleagues (and sometimes ourselves).  A great piece I read this month introduced me to some science in support of this phenomenon–The Dunning-Kruger is when low-ability individuals suffer from illusory superiority, mistakenly assessing their ability as much higher than it really is.  This effect is exemplified by the statement we don’t know what we don’t know– we may overestimate our skill and ability and FEEDBACK is critical to avoiding this. (interesting article on how this effect may have contributed to Trumps success in the election– http://www.politico.com/magazine/story/2016/05/donald-trump-supporters-dunning-kruger-effect-213904)

 

 

While NASCAR pit crew lessons can be applied to predictable events such as providing CPR the analogy to the battlefield is more appropriate for  complex medical or trauma events.  However through the use of checklists and a standardized approach to trauma we have standardized  our approach to make the unpredictable/infrequent predictable.

 

 

Marc Auerbach

Marc Auerbach

Associate Professor, Director of Pedatric Simulation at Yale University School of Medicine
Marc is co-chair of the Pediatric Academic Society’s Special Interest Group on Simulation-Based Research and co-chair of INSPIRE (International Network for Pediatric Simulation-Based Pediatric Innovation, Research, and Education). A self-proclaimed “super geek,” Marc’s research and educational activities leverage technology to improve patient outcomes.
Marc Auerbach
Marc Auerbach

Marc Auerbach

Marc is co-chair of the Pediatric Academic Society’s Special Interest Group on Simulation-Based Research and co-chair of INSPIRE (International Network for Pediatric Simulation-Based Pediatric Innovation, Research, and Education). A self-proclaimed “super geek,” Marc’s research and educational activities leverage technology to improve patient outcomes.