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Slide Notes
The first topic, the failed airway, is one of those sexy, bread and butter Emergency Medicine subjects that really cool educators who are smarter and funnier, and more experienced than me have covered in rousing talks at cutting edge conferences, on podcasts, and in other great FOAM venues.
The second topic, rebraining, is one you've probably never heard of since I'm sharing it here for the first time. It's about learning. Specifically it's about building the capacity for sustainable learning within our profession and across the arc of our careers.
As physicians, we spend a lot of time building our knowledge base and not much time understanding how to effectively maintain our skills
So the first topic is really the chocolate coating to get you to develop a taste for the second one. Perhaps when I'm done today rebraining will turn out to be the creamy nougat that makes the whole thing worth eating...
The second topic, rebraining, is one you've probably never heard of since I'm sharing it here for the first time. It's about learning. Specifically it's about building the capacity for sustainable learning within our profession and across the arc of our careers.
As physicians, we spend a lot of time building our knowledge base and not much time understanding how to effectively maintain our skills
So the first topic is really the chocolate coating to get you to develop a taste for the second one. Perhaps when I'm done today rebraining will turn out to be the creamy nougat that makes the whole thing worth eating...
Rebraining the Failed Airway: learning designed for humans
We spend a lot of time focused on what we need to learn. But in an era of accelerating complexity and disruptive change, the process of how we learn increasingly needs to be included in our focus.
As a physician, I live with the reality that sometimes our knowledge can fail us. When this happens we need to be able to access learning structures that understand how we learn, anticipate our weaknesses, and leverage our strengths. In short, learning designed for humans.
This talk is about my personal journey that laid the groundwork for using the concept of a self-education loop to "rebrain" myself after a terrifying failed airway experience.
MORE DECKS TO EXPLORE
PRESENTATION OUTLINE
Rebraining The Failed Airway
By Jonathan St George
The first topic, the failed airway, is one of those sexy, bread and butter Emergency Medicine subjects that really cool educators who are smarter and funnier, and more experienced than me have covered in rousing talks at cutting edge conferences, on podcasts, and in other great FOAM venues.
The second topic, rebraining, is one you've probably never heard of since I'm sharing it here for the first time. It's about learning. Specifically it's about building the capacity for sustainable learning within our profession and across the arc of our careers.
As physicians, we spend a lot of time building our knowledge base and not much time understanding how to effectively maintain our skills
So the first topic is really the chocolate coating to get you to develop a taste for the second one. Perhaps when I'm done today rebraining will turn out to be the creamy nougat that makes the whole thing worth eating...
The second topic, rebraining, is one you've probably never heard of since I'm sharing it here for the first time. It's about learning. Specifically it's about building the capacity for sustainable learning within our profession and across the arc of our careers.
As physicians, we spend a lot of time building our knowledge base and not much time understanding how to effectively maintain our skills
So the first topic is really the chocolate coating to get you to develop a taste for the second one. Perhaps when I'm done today rebraining will turn out to be the creamy nougat that makes the whole thing worth eating...
A True Story
At about 10:15am we received a call from EMS...
Click the audio button to listen to the full story of what happened to me on day two of my life as an attending emergency physician.
Click the audio button to listen to the full story of what happened to me on day two of my life as an attending emergency physician.
Photo by mckinney75402
transfer of knowledge
The traditional method for
The traditional transfer of knowledge learning model is dead. This doesn't meant that knowledge and experience can't be shared with others, simple that the process by with this occurs must address the demands of the future.
In my story as I discovered there were in fact many emerging ideas and approaches to the failed airway that I could have employed if I had known them.
In my story as I discovered there were in fact many emerging ideas and approaches to the failed airway that I could have employed if I had known them.
“If the brain is a learning machine, then it’s an eccentric one. And it performs best when its quirks are exploited.” - Benedict Carey
One of the first things I like to emphasize when unpacking the concept of rebraining is to highlight the continuing need in our profession to improve our understanding of how the brain learns, so that we can design better tools to help us keep our critical knowledge effective and ready for use.
This quote by Benedict Carey author of "How We Learn" sums up nicely the ethos of rebraining as a strategy. For a longer excerpt, click on the audio button to listen to me reading a key passage from the book.
This quote by Benedict Carey author of "How We Learn" sums up nicely the ethos of rebraining as a strategy. For a longer excerpt, click on the audio button to listen to me reading a key passage from the book.
DESIGNED FOR Humans
rebraining is Learning
Sometimes when we talk about learning and pedagogy we fall into the language of education and education research because we feel it lend gravitas to what is ultimately a murky subject. Sure we can talk about active vs passive learning, flipped classrooms, blended learning, spaced learning, and all the other terminology in pedagogy today. But let's remember four very practical things. Learning designed for humans must understand how we learn, consider the environment(s) we inhabit, anticipate our weaknesses and leverage our strengths if it is to be successful.
Designed for Humans
- Understands how we learn
- Considers the environments we (& our learning) inhabit
- Anticipates weaknesses
- Leverages our strengths
Sometimes when we talk about learning and pedagogy we fall into the language of education and education research because we feel it lend gravitas to what is ultimately a murky subject. Sure we can talk about active vs passive learning, flipped classrooms, blended learning, spaced learning, and all the other terminology in pedagogy today. But let's remember three very practical things. Learning designed for humans must understand how we learn, anticipate our weaknesses and leverage our strengths if it is to be successful.
Self-learning
A different process of iterative
We need to be here with you. Being unable to keep up with rapid change and a teacher is not a function of our lack of ability but a function of how we teach and what we believe our role to be.
Perhaps it seems too simple and so natural to us that we don't think it deserves much attention. But in fact this little loop is the engine of lifelong learning and collective knowledge and is worth examining. This is where we need to be with you as learners because this is where learners need to be. It's a bit less comfortable and a bit messier but the results can be astounding.
Perhaps it seems too simple and so natural to us that we don't think it deserves much attention. But in fact this little loop is the engine of lifelong learning and collective knowledge and is worth examining. This is where we need to be with you as learners because this is where learners need to be. It's a bit less comfortable and a bit messier but the results can be astounding.
self-education loops
BUILDING BLOCKS FOR
I felt that within this loop was the potential for all I would ever need to build sustainable learning process that would meet my "designed for humans" principles.
Untitled Slide
Over time I was able to fill in those steps in the self-education loop. and begin a process of reimagining a sustainable learning method for my career
Inhabit
Your Knowledge (take the red pill)
I don't do education research and I don't believe in grand education philosophies, nor do I have an educational agenda. What I believe is simple, as physician we must inhabit our knowledge.
Once you've gone through this talk come back and watch this scene from The Matrix again. It might be one of the best descriptions of learning challenge ever put to film.
Link to Video: https://youtu.be/zE7PKRjrid4
Once you've gone through this talk come back and watch this scene from The Matrix again. It might be one of the best descriptions of learning challenge ever put to film.
Link to Video: https://youtu.be/zE7PKRjrid4
Think Differently
About Failure (& Success)
Changing your mindset of learning from the traditional transfer of knowledge model. The biggest challenge to performing a cognitive reboots that it requires you to think differently about failure. While the process can be hard, it has a silver lining. By doing it you can move from a place where failure is so painful that it is ignored or glossed over to a place where it inspires new, creative thinking about a problem. It becomes the driving engine for improvement and the catalyst for change.
Link to Video: https://youtu.be/o_Ycw0d_Uow
Link to Video: https://youtu.be/o_Ycw0d_Uow
Think Differently
about learning as our shared responsibility to each other
Invest in yourself and invest in others. Self-Education loops ask you to do both. We must find the inner motivation to improve and learn but we must also be humble enough to ask help from others and be caring enough to share the product of our work freely with others so that collectively we are stronger. Learning designed for humans builds learning structures and resources that supports both the introspective and the social aspects of learning.
In order for learning to be sustainable it must have a deeply personal as well as a social motivation
In order for learning to be sustainable it must have a deeply personal as well as a social motivation
Photo by jonathan mcintosh
Untitled Slide
Step one of rebraining is often "performing a cognitive reboot" This requires honesty and introspection, tearing down your previous assumptions and inspecting it from top to bottom to seek out areas that led to failure.
This is not easy, we are used telling ourselves comfortable reasons for why we failed at something. "i wasn't feeling good that day, I didn't have the equipment I needed, I was given the wrong information to go on initially".
Basically what we are telling ourselves is, "I'm okay, nothing to see here, move along"...
This is not easy, we are used telling ourselves comfortable reasons for why we failed at something. "i wasn't feeling good that day, I didn't have the equipment I needed, I was given the wrong information to go on initially".
Basically what we are telling ourselves is, "I'm okay, nothing to see here, move along"...
failure
A misundestanding of
- I didn't fail because of my failure to intubate
I came to realize that what was at the heart of my failure was a fundamental misunderstanding of the nature of my failure
I came to realize that what was at the heart of my failure was a fundamental misunderstanding of the nature of my failure
Oxygenation
It Was a Failure to Prioritize
The number one failure in a failed airway that I see is the failure to recognize that the priority has shifted to oxygenation over intubation after intubation attempt(s) have failed.
Link to Video: https://youtu.be/JzlvgtPIof4
Link to Video: https://youtu.be/JzlvgtPIof4
Untitled Slide
The process of rebraining as a self-education loop has some required moments of deep introspection, but learning, even self-education, is a social process. It requires that we reach out to others and get feedback in order to evolve in our thinking.
Learning networks can be as informal as stopping a colleague in the hallway and asking their opinion; posting a question on your favorite social media platform or as formal as listening to a grand rounds talk, or going to a national conference.
In contrast to prior paradigms of asymmetric knowledge in medicine, a more distributive and connected world means the options for building your learning network and their necessity are greater than ever before. The key is to build them!. Spend time to cultivate your learning networks, nurturing and participating in them so that when you need them they are available for you to tap into.
Learning networks can be as informal as stopping a colleague in the hallway and asking their opinion; posting a question on your favorite social media platform or as formal as listening to a grand rounds talk, or going to a national conference.
In contrast to prior paradigms of asymmetric knowledge in medicine, a more distributive and connected world means the options for building your learning network and their necessity are greater than ever before. The key is to build them!. Spend time to cultivate your learning networks, nurturing and participating in them so that when you need them they are available for you to tap into.
Situational Awareness
& Three ways stress degrades it
Situational Awareness is a military term: it is the ability to identify, process, and comprehend the critical elements of information about what is happening to you and the team with regards to the mission. More simply, it's knowing what is going on around you.
Photo by Mariano Kamp
Cortisol
& some (okay a lot) of this
Sip of Water
Cortisol like a refreshing
Situational Awareness
& Three ways stress degrades it
Acute stress (you know) that adrenaline surging through you during the failed airway scenario is a key factor in how well you will perform and will rapidly degrade your situational awareness.
Link to Video: https://youtu.be/djyvLKqAxQc
Link to Video: https://youtu.be/djyvLKqAxQc
Photo by mag3737
Impaired Recall
What was it I'm supposed to do?
Impaired Recall.
You may have been able to recite the latest airway textbook chapter and verse on the subway to work, but add the chaotic environment of a crash airway into the mix and suddenly your memory recall isn’t so great.
See what stress can do to your memory?
Link to Video: https://youtu.be/WkFsgU_WLko
You may have been able to recite the latest airway textbook chapter and verse on the subway to work, but add the chaotic environment of a crash airway into the mix and suddenly your memory recall isn’t so great.
See what stress can do to your memory?
Link to Video: https://youtu.be/WkFsgU_WLko
Focus Lock
Almost there, almost there, almost....
Focus Lock.
As the stress mounts the desire to try and succeed with one more attempt at endotracheal intubation becomes a thought that overrides all others. Meanwhile your patient’s oxygen level drops to levels not compatible with life. This is focus lock.
Note insert solutions for this after this slide
As the stress mounts the desire to try and succeed with one more attempt at endotracheal intubation becomes a thought that overrides all others. Meanwhile your patient’s oxygen level drops to levels not compatible with life. This is focus lock.
Note insert solutions for this after this slide
Photo by rolfkallman
Normalcy Bias
I'M FINE, YOU'RE FINE, WE'RE ALL FINE...
Normalcy bias is one of the most common and most dangerous psychological phenomena: when facing a disaster many people underestimate the impending consequences of inaction.
Normalcy bias emerges from the cognitive dissonance of stress. Stress delays the mind's ability to process new information. In a failed airway situation, a physician may be unable to process the warning signs of a crisis, in order to "normalize" the situation they may also seek information to support the belief that the crisis is in fact not happening.
Here is a more complete description of normalcy bias.
Link to Video: https://youtu.be/e7u5_VMjWes
Normalcy bias emerges from the cognitive dissonance of stress. Stress delays the mind's ability to process new information. In a failed airway situation, a physician may be unable to process the warning signs of a crisis, in order to "normalize" the situation they may also seek information to support the belief that the crisis is in fact not happening.
Here is a more complete description of normalcy bias.
Link to Video: https://youtu.be/e7u5_VMjWes
Physical & Cognitive Impairment
part of my cognitive reboot: Failure to Accept Stress Causes
I had to rid myself of the belief that knowing the failed airway algorithm and being comfortable with an emergency cricothyroidotomy procedure was enough to keep me and my patient out of trouble.
I had experienced the effect of stress on my decision making ability first hand and realized that the first step towards a better performance during the next failed airway was acceptance of this fact and devising a strategy around it.
I had experienced the effect of stress on my decision making ability first hand and realized that the first step towards a better performance during the next failed airway was acceptance of this fact and devising a strategy around it.
Photo by toshi.panda
Untitled Slide
Because words matter, I've called them active countermeasures for a reason: these potential solutions to your problem are where the rubber starts to meet the road. The concept of active countermeasures is meant to push you in the direction of practical solutions not theoretical ones. It is the difference between physics and engineering, between the playbook and anticipating challenges of implementing that play in real-time.
Active countermeasures should be designed to stand in opposition to the obstacles and the chaos that can ensue in our busy work environment. It asks you to have deep knowledge of the world you inhabit, and time and space within which your solutions will live.
Active countermeasures should be designed to stand in opposition to the obstacles and the chaos that can ensue in our busy work environment. It asks you to have deep knowledge of the world you inhabit, and time and space within which your solutions will live.
Designed for Humans
- Understands how we learn
- Considers the environement(s) we inhabit
- Anticipates weaknesses
- Leverages our strengths
Sometimes when we talk about learning and pedagogy we fall into the language of education and education research because we feel it lend gravitas to what is ultimately a murky subject. Sure we can talk about active vs passive learning, flipped classrooms, blended learning, spaced learning, and all the other terminology in pedagogy today. But let's remember three very practical things. Learning designed for humans must understand how we learn, anticipate our weaknesses and leverage our strengths if it is to be successful.
Designed for humans
An example of a cognitive tool
The Vortex Approach is a great example of an active countermeasure.
http://vortexapproach.org
is a great example of learning designed for humans. More than just a teaching tool, it's creators describe it as a "high stakes cognitive tool" that takes into account not only how the brain learns, but also how it recalls information under stress.
In other words it's designed to anticipate our weaknesses, and leverage our strengths, to help us access critical knowledge when we need it most.
Their great design also shows us the positive impact that placing an emphasis on how we learn (not just what we learn) can have on our clinical care.
What does this mean for the evolution of medical education? It means not teaching to the classroom and leaving learners to work out on their own how to translate that knowledge to the bedside, but creating resources that live and work in real-time and inhabit the space between the classroom and clinical practice.
http://vortexapproach.org
is a great example of learning designed for humans. More than just a teaching tool, it's creators describe it as a "high stakes cognitive tool" that takes into account not only how the brain learns, but also how it recalls information under stress.
In other words it's designed to anticipate our weaknesses, and leverage our strengths, to help us access critical knowledge when we need it most.
Their great design also shows us the positive impact that placing an emphasis on how we learn (not just what we learn) can have on our clinical care.
What does this mean for the evolution of medical education? It means not teaching to the classroom and leaving learners to work out on their own how to translate that knowledge to the bedside, but creating resources that live and work in real-time and inhabit the space between the classroom and clinical practice.
Untitled Slide
When you get to the building your sandbox part of the rebraining process, that's where the fun really begins. For me this has always been the motivation dangle that I use to get myself to do the heavy lifting of the cognitive reboot.
Your “sandbox,” is a place where you can freely play around with the skill you’re trying to learn without having to worry too much about taking it seriously. The word sandbox is evocative of play rather than study, it is a place you build that lets you explore, experiment, and fail, without staking your entire future or reputation on it.
Most importantly, it’s an ideal environment for rapid learning.
To make it successful your sandbox should have three essential elements:
1. It must be affordable so you don’t delay in starting
2. Low-stakes: so you’re not afraid to fail or show your work
3. Public: so that you have to put your work out there in some manner
Examples
-Take on a quality improvement project
- Writing a department protocol
- Creating a learning tool for yourself and others
Your “sandbox,” is a place where you can freely play around with the skill you’re trying to learn without having to worry too much about taking it seriously. The word sandbox is evocative of play rather than study, it is a place you build that lets you explore, experiment, and fail, without staking your entire future or reputation on it.
Most importantly, it’s an ideal environment for rapid learning.
To make it successful your sandbox should have three essential elements:
1. It must be affordable so you don’t delay in starting
2. Low-stakes: so you’re not afraid to fail or show your work
3. Public: so that you have to put your work out there in some manner
Examples
-Take on a quality improvement project
- Writing a department protocol
- Creating a learning tool for yourself and others
Build Your sandbox
- Make if feasible
- Make it a safe space
- Make it public
Airway Box
Redesigned
3D Airway
Designing Better Practice
the failed Airway
Designing for humans: the conflating language of
When we design cognitive tools for humans we understand that words matter: that we see the world through language that words are filled with meaning, and therefore consequences, much of it often unintended.
In a failed airway scenario when our judgement is impaired by stress, it is surely possible even probable that the word failure in the failed airway algorithm has played a contributing role in a physician making one, or two, or even more attempts to intubate a hypoxic patient because "failure is not an option".
Is it time to flip the language of the failed airway? Laryngoscopy is a procedure that requires lots of training and a good bit of fancy technology to peer around corners in order to achieve visualization of the intended target. In contrast the surgical airway is a simple direct approach to the airway that circumvents the need for specialized tools. Why then don't we call it the direct airway algorithm? We call the procedure a cricothyrotomy which is an anatomical description but not a meaningful one.
In a failed airway scenario when our judgement is impaired by stress, it is surely possible even probable that the word failure in the failed airway algorithm has played a contributing role in a physician making one, or two, or even more attempts to intubate a hypoxic patient because "failure is not an option".
Is it time to flip the language of the failed airway? Laryngoscopy is a procedure that requires lots of training and a good bit of fancy technology to peer around corners in order to achieve visualization of the intended target. In contrast the surgical airway is a simple direct approach to the airway that circumvents the need for specialized tools. Why then don't we call it the direct airway algorithm? We call the procedure a cricothyrotomy which is an anatomical description but not a meaningful one.
Direct Airway algorithm
Because Words Matter...
When we design cognitive tools for humans we understand that words matter: that they are filled with meaning, and therefore consequences, much of it often unintended.
In a failed airway scenario when our judgement is impaired by stress, it is surely possible even probable that the word failure in the failed airway algorithm has played a contributing role in a physician making one, or two, or even more attempts to intubate a hypoxic patient because "failure is not an option".
Put this idea in your sandbox and play with it. Design a better cognitive tool the failed airwa
In a failed airway scenario when our judgement is impaired by stress, it is surely possible even probable that the word failure in the failed airway algorithm has played a contributing role in a physician making one, or two, or even more attempts to intubate a hypoxic patient because "failure is not an option".
Put this idea in your sandbox and play with it. Design a better cognitive tool the failed airwa
Photo by aesop
"We must be inspired to learn because what we learn has the potential to help others."
If there is one principle at the center of our being we must protect at all costs it is this one. It is the moral compass and the engine that drives me onward in my goal to constantly get better at what I do.
But it's easy to forget this in our current educational environment which often places testing and maintenance of certification over learning,
Rebraining is my method of holding on to this truth by allowing me to find meaning in my learning as well as personal joy in learning and sharing with those in my community at all levels of their training.
But it's easy to forget this in our current educational environment which often places testing and maintenance of certification over learning,
Rebraining is my method of holding on to this truth by allowing me to find meaning in my learning as well as personal joy in learning and sharing with those in my community at all levels of their training.
Rebraining
You May Now Commence
Deeper Cuts
The deeper cuts for this talk are buried within the slides themselves. Just click on the audio or video button to hear more of my thoughts on this topic or check out curated content that inspired me along my journey in developing the concept of rebraining and self-educations loops.
The video on this slide is a recent post from my friend Cleavon (a resident in our program) who has just built his youtube channel sandbox, and it's SICC!!! (click on the video and you'll understand....
Link to Video: https://youtu.be/c6No1CHQWcU
The video on this slide is a recent post from my friend Cleavon (a resident in our program) who has just built his youtube channel sandbox, and it's SICC!!! (click on the video and you'll understand....
Link to Video: https://youtu.be/c6No1CHQWcU
Study Playlist
Everyone Needs a Good
While your your deep in thought doing a cognitive reboot or designing your active countermeasures you might need some inspiration and focus so here is my current favorite Study Playlist of Spotify:
https://open.spotify.com/album/1C2XQna0yEhWcvoBP5xTBz
Bill Murray reads American classics accompanied by a classical trio. It was created with the help of Jan Vogler, a German cellist and I was surprised by how much I loved it.
https://open.spotify.com/album/1C2XQna0yEhWcvoBP5xTBz
Bill Murray reads American classics accompanied by a classical trio. It was created with the help of Jan Vogler, a German cellist and I was surprised by how much I loved it.
Photo by wu yi
