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Do You Want To Play A Game?

We are only human, right? Some of the cool features that come with be being “Only human” include: forgetfulness, loss of situational awareness, and an amazing ability to make stupid mistakes. Oh right, let’s not forget about loss of concentration and freezing up, either.

All of these are equally as awful; in a world where the expectation is that we function perfectly. No pressure. Just imagine yourself in a small room where you are trying to solve math problems or riddles; or listen to a passage which you are expected to memorize; all while there are is someone performing a drum solo in the corner. I feel like this is a good comparison to what we deal with while working in the variety of healthcare environments in which we do, such the hospital, an ambulance, or in flight. A lot of thinking has to be performed with a TON of distraction. Those cool human features I described (better known as human factors in the world of CRM) have a tendency to take over as we are expected to execute flawless patient care.

Albeit farfetched and fictional; the movie Saw provides us with a great example of performance under pressure. The characters in the movie are at the mercy of Jigsaw; who tasks them to complete complex puzzles or “games” in order to spare life of one another; their families, or themselves. No looming pressure or distractions, right? It’s only someone’s existence in your hands. The characters must beat the clock, and may even have to deal with moral dilemmas thrown in the mix. So. Much. Pressure.The point is, that as critical care transport clinicians, where we are tasked to perform under pressure on a daily basis, and cognitive overload is ever-present, even when not taking care of the sickest of patients. The multitude of conflicting needs and demands that we come across during all patient encounters often leads us to become task-saturated and perhaps overwhelmed. Even during transports which are considered “easy,” such as taking a stable STEMI to a cath lab; the same expectations exist to achieve safe and high-quality care; just as when caring for a complex ARDS patient. Also expected of us as providers, is a duty to produce an outcome for our patient; and this has much to do with processes which we must follow to achieve this. These may or may not be spelled out clearly, but the goal remains the same: to ultimately provide care and safely transport the patient; regardless of condition or acuity.

Next up: Freezing up.

We may not realize that we are under pressure, or sometimes we don’t want to admit it. In David McRaney’s book You Are Not So Smart; McRaney discusses various heuristics and cognitive biases, and one stands out as extremely applicable to what we do - “Normalcy bias.” McRaney describes normalcy bias like this- When we encounter new, and perhaps alarming situations, we measure and process these up against what we know through our own experience, or what we perceive to be “normal.” In doing so, the brain processes this otherwise alarming, or stressful situation; as business as usual. Basically, we may become so overwhelmed with this abstruse information that there is just pure inaction, when action needs to be taken. The pressure we think we are not under may certainly be there, and it may sneak up and bite us in the a**. Stalling out, freezing up, stage-fright….whatever you want to call it. This is another lovely feature of our humanity which can rear its ugly head when we absolutely do not need it to: When a patient may be crashing in front of us. The question is, how can we overcome this?

Human factors vs. Superpowers

Another thing we have going for us? The ability to lose situational awareness very easily. We work together as a crew, and we often join other providers throughout a transport and become part of a larger team. This happens when we get in an ambulance in the pre-hospital setting; or when we enter the confines of a hospital room with all types of clinicians present. As we all work for the outcome we are tasked with producing for the patient; order must be maintained. The more people in the mix, the harder order is to keep. How things are actually going vs. how we perceive them may work against us if everyone is not “In the know.” There has to be that mental or cognitive off-loading in order to overcome this. The corralling of the situation. I am a firm believer in the timeout. Everyone is forced to stop and take a hard look at the situation. Stop, Collaborate, and listen.

I know there are a ton of mnemonics in healthcare, and I created my own in order to keep myself, and whomever is working around me; in check. Regain and maintain the situational awareness. I talked about this at a couple of conferences, broke it down; and I want to get others on board with the simplicity of this and how much of an impact it may have during patient care. It works for me (someone who you can call scatter-brained) and I wanted to share it with the world. I consider this my superpower when on any transport. Call it corny, but it is very useful.

Simple, easy, and an actual word. PIVOT. This is a tool for timeouts. So basically, these are 5 very simple factors that are stated during the timeout. I dubbed these timeouts “PIVOT points.” Get it? …With that being said, let me break it down. The P is for Patient.This is age, sex, weight. The I is for Illness/Injury.Keep this simple (STEMI, trauma, sepsis..ARDS..etc). V is for Vital signs.The vital signs give the current physiologic overview of the patient. The O is for Other interventions.This refers to the pertinent interventions that have been performed for the patient. Such as Infusions, intubation, chest tubes..etc. I am not talking about a knee replacement that occurred 6 years prior. The T is for To do. This is where we decide what actions we are going to take next based on the P-I-V-O or prior information. Just make sure that everyone is on board with the To do. You can even say, “Does everyone agree with this?”

To complete this time out, you only need seconds. Here is an example of when you go through this at your first suggested PIVOT point, which is after you get report and make patient contact. Say the information out loud, so everyone hears it. “Everyone” is the team at the bedside; or maybe just your partner.

“The (P) patient is a 65-year-old female who weighs 70kg with a diagnosis of (I) Sepsis. (V) Vital signs are as follows: The patient is responsive; HR 116, BP 120/80, SPO2 98%, ETCO2 30. (O) The patient is intubated and mechanically ventilated; tolerating settings well. Levophed is infusing at 4 mcg/min. We only have one point of vascular access (T) we need to obtain additional IV access and provide analgesia and sedation.”

The first PIVOT point is complete. Now that you have a plan, and everyone is on the same page with what we have going on; and what we need to do; Do that thing! Once we have completed our To do, we keep working until we reach our next PIVOT point. You go through it again, and perhaps based on what you have done, your vital signs may change, your other interventions with definitely change, as will your next thing or To do. Say you did obtain additional IV access and provide analgesia and sedation:

“The (P) patient is a 65-year-old female who weighs 70kg with a diagnosis of (I) Sepsis. (V) Vital signs are as follows: HR 108, BP 110/72, SPO2 98%, ETCO2 30. RASS -4 (O) The patient is intubated and mechanically ventilated; Levophed continues to infuse at 4mcg/min, and Fentanyl 70 mcg IV was administered. Propofol is infusing at 20mcg/kg/min, and we established an 18 gauge IV in the left AC. (T) We can now move the patient onto the transport vent and pumps; then prepare for transport.”

Second PIVOT point: complete. This continues as often as you need it to. If no treatment has to be performed as part of your To do; this may end up being as simple as “Monitor and transport…”

My suggested PIVOT points are:

  • At the time of patient contact after receiving patient report

  • Prior to leaving the bedside

  • Once loaded into the aircraft or ambulance

  • During transport (As often as you need)

  • Upon arrival at receiving facility

  • At time of transfer of care

Speaking of transfer of care, this is a great tool for that! You have repeated this information (out loud) so many times by now during transport that when it comes to giving a report to the two nurses in the ICU, or to the 100-person team in a trauma bay that expect a 30 second blurb, you can give this information with ease and not miss a beat. Say you are transferring care on this same patient:

“The (P) patient is a 65-year-old female who weighs 70kg with a diagnosis of (I) Sepsis. (V) Vital signs are as follows: HR 110, BP 112/70, SPO2 98%, ETCO2 30. RASS -4 (O) The patient is intubated and mechanically ventilated; Levophed continues to infuse at 4mcg/min, and Fentanyl 70 mcg IV was administered. Propofol is infusing at 20mcg/kg/min, and we established an 18 gauge IV in the left AC. Transport was uneventful with no further intervention.” (T) Transfer of care…

You give a clear and concise report, and you look cool and confident. Of course, the team may ask for additional information such as ventilator settings, or tube size and depth, but you got the meat and potatoes out of the way. If you must contact a medical command physician in flight or the receiving hospital; use these five pieces of information for your short and sweet report as well.

This is a great tool to use with your partner or with others. Like I said, this particular mnemonic may not be your cup of tea, but you can always come up with what works for you. Organizing your thoughts in this way provides a safety net to help keep you from losing your situational awareness. You are constantly aware of the state of your patient, as is anyone else who is present with you taking care of that patient at that time. So, this is my crazy idea that I hope some of you can benefit from and use in your practice. Most of all, the one who should benefit is the patient.


McRaney, David. (2011) You are not so smart :why you have too many friends on Facebook, why your memory is mostly fiction, and 46 other ways you're deluding yourself New York : Gotham Books/Penguin Group,

Ami Tomaszewski (@amitomaszewski)

Flight Paramedic

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