I was driving down the city street on a sunny day in Wisconsin. My mind was deep in thought about an upcoming lecture. My wife looked over at me and said, “umm, how long are you going to leave your windshield wipers on?” At that moment, I realized I had been driving for some time and didn’t even realize that directly in front of me, two black wipers were going back and forth, making a screeching noise on my windshield. Situations like this intrigue me and cause me to take a closer look at the factors that reduce our ability to maintain situational awareness. We commonly hear the terms “task saturated,” “tunnel vision,” and “cognitive overload.” Do these terms refer to something we should avoid, or are these innate characteristics that we just need to be aware of? How does one maintain an “OAAT” mind frame of mentally sterile procedures that Sam Ireland spoke of in his blog and maintain a big picture view of the patient?
I spoke with Michael Lauria on the phone the other day regarding these questions. Mike was a Pararescueman (PJ) in the United States Air Force. He writes about human factors, stress response, and how they affect our performance.
I asked Mike, “how can I maintain focus on a task while still maintaining situational awareness?” His short answer was.....” you can’t.” Multitasking is a myth, and something will always suffer when you try to spread your cognitive bandwidth too thin. Then how does one maintain situational awareness while performing a cognitively heavy skill? Usually, it takes more than one person. You will have one person with their “eyes in” or focused on a procedure/task and the other with their “eyes out” maintaining situational awareness. This is why during aviation procedures, the pilot will maintain flying operations and manipulate the aircraft while the co-pilot works down a checklist. This can be contrasted with the teamwork needed during sequenced intubation. One provider will be absorbed in the task of prepping and performing laryngoscopy (eyes in), while the other (eyes out) is watching monitors, pulse ox, etc. Can we train ourselves to do both? Mike explains that certain tasks such as spiking an IV bag or placing a tourniquet can be performed while maintaining a certain degree of situational awareness. However, anything requiring advanced motor skills or brain function will always diminish a percent of peripheral perception.
We can train ourselves to disconnect from a task and evaluate our surroundings temporarily, but this takes a fair amount of discipline. Which explains why we see so many motor vehicle accidents as a result of texting. Once someone has their mind set on a reply and typing, they forget to look back up, or peripheral perception becomes diminished.
The Elaine Bromiley case is an excellent example of an entire team that went “eyes in.” No one was watching the big picture, and the patient was the one who suffered in the end. When watching this video, it seems so obvious! How could they miss this?! This is because we are looking at the big picture. Watch the video here.
My friend Brian Behn referred me to a book called “Black Box Thinking.” In the intro to this book, they contrast the way we react to mistakes in medicine vs. the way these are handled in aviation. The difference is in aviation, the pilot’s life is involved in the decision-making and actions. In medicine, mistakes can easily be chalked up to “this patient was just really sick,” and we go back home at the end of the day. We have to look at the big picture when caring for our critically ill patients, and when we can’t because we are “eyes in”, make sure someone else is “eyes out.”
Check out Michael Lauria's work on human factors and decision-making.
How do you maintain situational awareness while still going eyes in?
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