Simulcast Journal Club February 2018 – Sound and Fury

Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field. 

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you. 

Copy of Journal Club

Title :  “Sound and Fury 

The Case :  

For a brief moment in the chaos, time had seemed to pause.   The cacophony in the resus room was rising but through it all the quiet wail of the infant’s parents was cutting through it all as if their grief was physically squeezing Cath’s heart. 

She felt the vivid tremor of her hands. 

In that instant it was as if she could physically see the emotions in the room, manifesting like coloured balls of light that bounced and echoed around the bedside.   

She saw her Fellow Nitin knock away the cannula tray and reach for the Intraosseous, the stress glowing a vivid red from within his chest. 

She saw Harriett the social worker kneeling by the parents’ chair, shielding the team from some of the thick, black grief that poured out through their tears. 

Brad and his team from ICU had walked in and gravitated straight to the ventilator.  He was a wonderful man but she could feel his frustration with the team brewing.  She had been friends with him long enough to know he was about to snap, and the fact she was disappointing an old colleague filled her with a yellow flush of shame. 

As her panic began to overwhelm, the nursing team leader moved into Cath’s field of vision.  She spoke just loud enough to be heard.   

“You’ve got this.  We’re here for you.”. 

Cath closed her eyes and slowed her breathing. 

It was time to take back control. 

The Article : 

Hicks, C. and Petrosoniak, A. (2018). The Human Factor. Emergency Medicine Clinics of North America, 36(1), pp.1-17. 



Destined to become a classic paper we are pleased to feature Hicks & Petrosoniak’s newly released from Emergency Medicine Clinics of North America.  While not specifically focused on simulation, ‘The Human Factor’ takes knowledge formed and refined within the simulation room and translates it back into clinical practice. 

As Simulation Educators many of us have been conduits for bringing the gospel of CRM into the healthcare workplace and as such this paper provides an important deep dive into current thinking on human behaviour and training strategies to improve our performance in a crisis. 

We look forward to hearing your thoughts on this paper, and in particular :  


  1. What strategies from this paper might help Cath’s team regain control of a chaotic situation? 
  1. How might this paper effect your educational practice and debriefing strategies in CRM? 
  1. Will it effect your clinical practice as well? 


References : 

Hicks, C. and Petrosoniak, A. (2018). The Human Factor. Emergency Medicine Clinics of North America, 36(1), pp.1-17. 

About Ben Symon

Ben is a Paediatric Emergency Physician. He is based at The Prince Charles Hospital in Brisbane. In 2014 Ben was the first Simulation Fellow for Children's Health Queensland, and assisted in the statewide roll out of the SToRK Team's RMDDP program. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

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15 thoughts on “Simulcast Journal Club February 2018 – Sound and Fury

  • Suneth Jayasekara

    Hi Simulcast team – nice to see the journal club back online after the festive break! Thanks for sharing this great article – so much goodness in it, that I would need to read a few more times to absorb it all! So much relevance for us simulation educators, even though its not specifically a simulation article.

    They talk of strategies of optimising management of individual, team, enviroment and systems – and I think that as sim educators we can contribute towards improvment all 4 of these aspects.

    From an individual point of view – sim educators can focus on helping individuals deal with acute stress, by training performance enhancing psychological skills – PEPS (as outlined in the paper by Lauria et al, Annals of EM -2017). Stress innoculation training can be used for this. Also “overlearning” as mentioned in this month’s article, can be trained via procedural skills training sessions on part task trainers. Team related factors are generally covered in sim education – but specifically targetting the use of a resuscitation lexicon as dicussed in the article, and explicitly discussing closed loop communication and shared mental models in the debrief could be done. The use of subteams to achieve simultaneous complex tasks could also be effectively practiced in simulation. Regarding environment and system improvements – thats where in-situ/ translational simulation has an opportunity to shine. In fact the use of this is specifcally mentioned in the article.

    Regarding your questions
    1. To regain control of the resuscitation – Cath would first need to control her own stress. She could use the PEPS techniques of square breathing, positive self talk, mental rehearsal and focus to ensure she is in an optimal arousal state. Then she would need to get control of the team by sharing her mental model of the situation, and allowing others to share theirs during a quick pause point in the resus. For the environment – a senior nurse could be allocated to take the role of the logicstics and safety officer, to ensure optimum functioning.

    2. As dicussed above – the aspects brought up in this article could be dicussed more explicitly in the debrief. Deliberate practice of the resuscitation lexicon could be done via dedicated training

    3. As with most things taught and learnt in simulation – will certainly affect my clinical practice as well!

    Thanks for sharing a great article – looking forward to the discussion!

    • Ben Symon

      Thanks for starting the conversation Suneth! It’s great to hear from you again.
      I agree it’s a very dense article that has a LOT of learning in it, and it’s definitely going to take me some time to absorb it all.
      I agree that as Simulation Educators we have a lot of opportunities to help staff learn to cope with stress in a resus, and while Sim in some ways innately helps with that, I worry sometimes that at the CRM courses I attend, things are kept to a very superficial level, ie. “Was there closed loop communication?”, “Were you aware of your environment?”, “Was there clear leadership?”. And on some level I think a lot of that basic CRM knowledge has already gotten out there now, and people know what to say. I think this paper will help me ‘dig deeper’ in my debriefs as well about the quality of communication and the approach of the staff to emotional containment.

  • Victoria Brazil

    Wonderful article and great case Ben.
    I’ve already waxed lyrical about this paper on the podcast, but great to dissect it a little deeper.

    I really like how the paper breaks down the individual, team and system strategies, while recognising they are intertwined. Cath would clearly do well with the individual self management techniques described, but the case illustrates how its also the responsibility ( and opportunity) for others on the team to trigger those manoeuvres when they sense distress.

    This has already had an effect on my educational practice.

    1.Any scenario where there is some measure of cognitive overload on participants I like to discuss those individual techniques (even to medical students), as well as the strategies for re-distributing task work.

    2. The ‘sub team systems’ / ‘divisional structure’ is something we’ve also come to in our trauma team training, and are actively encouraging more subteam autonomy to off load team leader.

    3. ‘Overtraining’ – last month our trauma sim was… sim – debrief – sim again – debrief again. And we’ll be looking to vary our formats

    4. New points of reference for the ‘deeper dive’ discussion in the debrief than how I’ve previously used CRM. I think thats because i’ve interpreted CRM narrowly as a set of behaviours. Good but not enough – and this paper has extended my view and lexicon for that

    I’ve still got some work to do embedding some other strategies that I’ve heard Chris Hicks talk about for a couple of years, and we’ll get there.

    My only issue with the paper is that i wonder if they should have published as a 3 part series – as there is so much to take in here.

    Thanks again


    • Ben Symon Post author

      Thanks Vic, I look forward to hearing more about your overtraining!
      I agree with you about maybe breaking down this paper into a few more chunks. It’s less a full course meal and more an elaborate 17 course banquet of dense, finely crafted information that defies summarisation.
      I wonder whether the limited number of comments this month is in part due to the length of the article?

  • Sarah Janssens

    I’ve read this meaty article a few times now and always get something more out of it. I really enjoyed the way that individual, team and environmental factors were separated, acknowledging that this are never separate.
    I’ve passed on the 5 tips for individuals to manage their stress to all of our trainees – perhaps I’ll spark an epidemic of self talk and heavy breathing?

    What really struck a chord with me was the way they highlighted the importance of functional team structures and the idea of the LSO – logistics/safety officer. In maternity we lack formal emergency team structures of trauma and some code teams, although our senior midwives frequently function (implicitly) in the LSO role. I have seen this role named “event manager” , but I’m really drawn to the way that the LSO title defines what the responsibilities of that role are. I would like to see this sort of role be more explicit in our teams and I’m hoping we can use sim to teach and rehearse this role.

    • Ben Symon Post author

      Thanks for your thoughts Sarah!
      It’s great to hear your perspective from an obstetrics background. One of my minor irritations with this beautiful paper is that is specifically brands itself as an article to optimise trauma teams. The principles involved are so universal and important that I think the subtitle of the article undersells itself.
      What I’m hearing from your comments is that this article appropriately challenges our perceptions of what specific resuscitation roles can be, and moves it away from a physiological and heirarchical viewpoint, to one in which empowers us to identify the needs of the team more explicitly.
      Paediatric Resus, for example, very well often needs a parental communication officer who would not only take a history but reassure/inform parents on resuscitation interventions taking place. I think there’s a lot of power in naming a task like ‘event manager’ in that it provides focus and authority at the same time.
      Thanks so much again for your comments!

      • Derek Louey

        Hi Ben,

        I think there are unique aspects of managing a critical multi-trauma patient that have no equivalent in a ALS/APLS scenario. It is probably the one situation I reflect most often to improve my future performance. I love reading Chris’ reflections on Human Factors which seem to articulate exactly what I have been thinking and why a messy trauma often feels so chaotic.

        I think we sometimes under-emphasize how the behaviours of team members can impact on the performance of the leader. Good members can make an average leader appear masterful. Dysfunctional members can push a good leader to her limits.

        Not even considering the major clinical decisions (often based on incomplete data) that need to be made, there can be a huge amount of information that needs to be processed in a highly changing situation. This is often exacerbated by the behaviours of junior members in the team or poor ‘follower-ship’. Causes for extreme cognitive overload for the leader include:

        1) Having to acknowledge and process several important messages occurring at the same time whilst simultaneously trying to filter out or suppress the clamour of extraneous, secondary or redundant chatter (e.g. ‘I have a CVCI situation’ ‘There pericardial fluid’ ‘I can’t get a pulse’, ‘I’m not familiar with this crike kit’, ‘This BP cuff won’t fit’ )
        2) Sequencing the order of several critical tasks that cannot be logistically carried out simultaneously (‘Doctor 1 can you establish large bore access on the right side whilst Doctor 2 begins prepping for an thoractomy on the left side, Nurse 1 – Can you step back and forget about putting a blood pressure cuff on until we get a carotid pulse back’)
        3) Micromanaging the performance or decision of team members (e.g. ‘Don’t bother with the second intubation attempt, we need to establish a surgical airway immediately. No. Forget about the LMA’)
        4) Resolving conflict between members of the team in a time-pressued situation who often do not work together (‘e.g. we should start the thoracotomy in the resus room and not wait to do it in theatre’)
        5) Responding to a rapidly changing situation and then re-priortising or re-tasking people (e.g. ‘the patient has now a shockable rhythm, Doctor 2 forget about the arterial line and make preparations for internal defibrillation whilst Doctor 1 continues internal massage’

        More thoughts on Follower-ship”


    Thank you Ben for a great start for 2018 Simulcast Journal club

    I always enjoy reading your case study (you make them entertaining with your unique style of writing 🙂

    I have to agree with all the comments about the article being “meaty “and that the material that has been covered in one article can be done over multiple articles. Also the information / techniques in this article can be transferred to all teams NOT just only Trauma teams.

    Here are some points that I would like to share with the you:
    • Breaking down how to manage complexity in health care systems during (trauma or resus) into 4 domains and addressing each domain equally. This really impressed me as some articles only focus on one or 2 domains and don’t put enough weight in the other domains.
    • The article managed to analyse the issues and give practical advice and solutions/options which makes it a very strong article that health care providers across the health system will always use and refer to.
    • The following sentences /phrases in the article were the highlight for me and pleasure to read and reflect on and I like to share them with you all :
    “A gap between strategy (the plan) and logistics (how that plan is executed) often arises from a lack of consideration for and preparation of the operational environment”

    “High-performance teams maintain open and flexible lines of communication”

    The authors use a 4-step structured prebriefing process:
    What do we know? What do we expect? What we will change? Roles.”

    “By examining what goes well in addition to what went wrong, systems can identify elements
    of resilience and adaptation that can be applied proactively to prevent error.”

    “Resilience is built, not born, and there is no single strategy that reliably manufactures
    resilient performance in all circumstances”

    • Finally, I think Victoria has brought up a great point of using these strategies and technique during our under graduate simulation sessions. By planting the seed as early as medical school training we are preparing our health care systems and our future doctors very well.

    Thanks and looking forward for your end of month rap up session on this article .

  • Lauren Kennedy

    Hi team! I’m trying to be good this year and actually read the journal club article rather than rely on the podcast – I think you are on the money Ben with the long article slowing people down, especially as there is so much gold to wrap your head around in the article. I think I am starting to get there though! (So, yes, a three part series would have been nice!)

    I also agree that specifically talking about trauma teams very much narrows what is really an otherwise quite broad application. However, with recent literature reviews and other research I have been looking at, sadly this isn’t new – surgeons are much better at publishing (trauma) team training initiatives and programs (closely followed by midwives/obstetricians with ALSO and other courses) than ED or ICU are at publishing ALS/APLS training programs – or other team training initiatives. At the same time though, this has meant that I had to be more reflective while reading through the article looking for parallels with more commonly encountered situations.

    I have really enjoyed reading the ways in which in situ simulation can be used for systems and team based applications – both in new and established settings. It is very much something that I want to look at using more in the future. The focus on ensuring positive points, especially from a systems perspective, are used for learning, instead of the usual negative points is something I need to keep in mind. I think it is a matter of taking the generic “what do you think went well?” a step further and prompting learners to think about both why the identified component was “good” and how that can be applied in the future. In terms of my own clinical practice, I have been deliberately taking a moment longer to prepare and focus on complex tasks since first looking at the paper, and so far with positive results.

    • Ben Symon Post author

      Thanks for joining us Lauren, it means the world to me have someone come join us in the discussion.
      It’s an interesting point you raise with regarding ED/ICU being a lot slower than our Surgical colleagues. Not having done a lit review on the issue I wasn’t aware that that was the case!

      What sort of complex tasks have you been preparing for? Did you mean in a clinical setting or in a teaching setting?

      • Lauren Kennedy

        No worries Ben – was enjoying the podcasts driving between home (Adelaide) and Mildura doing some rural time this year, and caught up on a lot of stuff over the Christmas break and decided to try to keep more up to date for 2018.

        Has been a bit of both really – I have just started my ICU rotation (as an ED reg) so have been doing more procedures than usual – whether relatively new procedures or procedures I had been relatively comfortable with that require variation when the patient is intubated. I don’t have as many teaching responsibilities at present as I usually do, but even so when I have been working with students I have been trying to help them slow down more as well to help them comprehend the complex patients in the unit.

  • Bishan Rajapakse

    Hi Ben,
    thanks for sharing this brilliant paper, which beautifully outlined some helpful cognitive frameworks to help make sense of the complex task of trauma management. I would like to echo the your sentiment somewhere in the discussion thread that suggests that the principles contained within are perhaps more universal might be implied by the authors.

    To elaborate further, I wonder if the concepts of managing “Self, team, environment and system” relate beyond management of complex resuscitations or trauma,to the macro level of management of entire emergency department? I thought the concepts were quite transferrable, which is one of the reasons that I found this paper particularly helpful and fascinating to read (…perhaps my interpretation of the article is jaded by the fact that I’ve just finished a set of ED nights in a busy trauma centre).

    The two areas that seemed to be most interesting was the section on “stress and performance” and the techniques for addressing this. The two step cognitive appraisal model that they described (i.e. Demand>resource–> threat, Resource>Deamand –> Challenge) is a brilliant way to understand how stress can arise in many ED contexts. Applying this model to the broader context of “running an Emergency Department, for example, with the scenario of a busy department during the middle of a night shift, and ambulance still coming in, it is easy to see how a demands >> resources (cognitive, personnel, and systems-based) situation could easily be perceived, and an appraisal of “Threat” being calculated. The stress management techniques are equally as relevant in this context, as are perhaps the strategies to train to operate more optimally in this setting.

    Anyway, just a perspective I thought I’d share.

    Great article!

    • Ben Symon Post author

      Thanks so much for your thoughts Bishan, it’s always great to hear your perspective. I agree that breaking down the underlying factors that create stress goes a long way to helping us cope with it. What I like about the paper is that it also gives us specific coping strategies to deal with that reality too. Hope you’re enjoying some post nights days off.