You arrive at the scene of a road traffic collision, where a motorcyclist is trapped under the front wheels of a car and has noisy breathing. The driver of the car is agitated and complaining of chest and neck pain, and requires urgent assessment and c-spine immobilisation, while the fire service reports they are on their way.
Managing scenes like this requires sustained, high-level communication between crew members, ongoing complex decision-making and a sound understanding of crew resource management (CRM) principles. However, in such a chaotic scene and with limited resources, it is not unusual for one or all of these elements to be missing, which couple potentially lead to adverse patient outcomes.
World Health Organization (WHO, 2020) figures demonstrate that a significant number of adverse events affect patient care, even in controlled, low-risk environments such as hospitals. In comparison, out-of-hospital settings are high-risk environments in terms of patient safety, owing to fast-paced, unpredictable circumstances coupled with the increasingly complex interventions being provided by paramedics (Hagiwara et al, 2019).
To be able to respond safely to complex scenes, paramedics must be able to not only draw upon their many years of experience and their formal education, but also understand how high-demand, high-stakes situations affect the human response. In addition to making errors because of environmental factors, paramedics are human beings who will respond on a physiological level (e.g. with catecholamine secretion). This may produce unwanted physical effects such as palpitations, diaphoresis and tremor.
Although, at a psychological level, this may provide a temporary performance benefit while carrying out some simpler tasks, it may be detrimental for more complex functioning as levels of stress increase. This concept was encapsulated by Yerkes and Dodson (1908); their well-know Yerkes and Dodson law of arousal (Figure 1) states that, while simple tasks may cause high arousal levels (stress), performance is significantly higher, leading to a better-quality outcome. Inversely, more complex tasks have a threshold or a plateau above which performance diminishes with high arousal levels.
Applying the Yerkes and Dodson law of arousal to the scene described shows that it can be anticipated that high-quality care cannot be sufficiently maintained. However, delivering a reasonable yet safe level of care should be expected in such circumstances. Applying the Yerkes and Dodson law should allow the paramedic to make the best choices in the circumstances they are in until additional help arrives.
Reducing error and therefore harm in the out-of-hospital care setting, first and foremost requires systems that promote safety (Willis and Pocock, 2019) and the authors suggest that synthesis of the egg-timer model of disparity (ETMD) by Summers and Willis (2010) in combination with the Zero Point Survey (ZPS) by Reid et al (2018) is worthy of exploratory review. These frameworks recognise the importance of applied paramedic clinical leadership skills and scene control in combination with crew resource management to reduce both psychological burden and potential for error.
Background
Paramedic working environments are highly complex, unpredictable and fraught with risk. If paramedics are to arrive safely at their patient's side and deliver high-quality, person-centred care, they must not only understand the human factors that might get in the way of delivering that care, but also have strategies for dealing with such situations. As noted, two frameworks that might be useful in such circumstances are the ETMD (Summers and Willis, 2010) (Figure 3), and the ZPS (Reid et al, 2018).
Egg-timer model of disparity
The ETMD is a theoretical construct that provides a cognitive and visual representation of how paramedic crew members should aim to bring their thinking and actions in line when managing cases. It gives a valuable visual representation of the potential for a difference of opinion between clinicians, which may result in a disagreement pathway, ending in conflict between crew members and potentially to a negative impact on patient care and patient safety.
The model suggests using clear communication along with maintaining a cohesive working relationship through considering human factors and applying CRM techniques to lead to the best patient care outcome (referred to as the ‘settlement pathway’) (Summers and Willis, 2010).
Applying this model to the aforementioned scenario would allow the paramedic crew to get together and discuss their priorities, allowing collective decision-making to take place. Taking such actions in the heat of a complex case might allow any differences of opinion to be identified and considered to aim for a settlement pathway. For example, providing spinal immobilisation in such a situation might not be a reasonable use of person power. Therefore, possible alternatives can be discussed and implemented until further resources arrive.
Zero point survey
The ZPS and its STEP UP mnemonic (self, team, environment, patient, update and priorities) were developed as practical means to optimise the performance of in-hospital resuscitation teams, and were designed by clinicians from Australia, Canada, England and the United States (Reid, 2013; Reid et al, 2018).
The model draws together a number of CRM and personal performance strategies to allow a team leader to guide an efficient and effective resuscitation attempt. It has several aims, which include to gain maximal benefit from the pre-arrival phase (in terms of personal and team preparation); reduce practitioner stress; provide prompts for setting a clear trajectory of care; and minimise disruption caused by disparities of opinion within a resuscitation team (Figure 2). It is designed as a real-time aide mémoire for clinicians caring for critically unwell patients.
The use of the ZPS, as something that is started before the primary survey, has been suggested as one approach to bringing order to the potential chaos of a resuscitation (Reid, 2013). The STEP UP mnemonic in the ZPS provides a framework for the resuscitation of a critically unwell patient, beyond the basics of the primary and secondary surveys (Reid et al, 2018).
ZPS in paramedicine
While the ZPS was originally intended to be applied to in-hospital patient management, the authors of the present paper recognise its transferability and usefulness to the out-of-hospital setting. Approaching a critically unwell patient requires a safe, systematic application of physical and psychological techniques to ensure paramedics can function in a dynamic setting where only two of them are present (as opposed to a full team as seen in hospital) in stressful circumstances.
Paramedics have additional stressors to manage while delivering out-of-hospital care compared with in-hospital care: among them, adverse weather, patients' relatives in crisis, unsecured or hazardous scenes and time pressures related to extrication and onward transport. These conditions create a clear need for a framework to allow paramedics to apply strategies to optimise personal performance and enact CRM techniques that will ensure the provision of high-quality patient care.
The ZPS offers a leap forward in terms of resuscitation management by providing an easily accessible synthesis of previously proposed concepts and ideas. It has the potential to facilitate effective practice in a team leader through effective personal and team preparation before direct patient care as well as by encouraging a cohesive team approach to patient management and the setting of care priorities. It does this by emphasising teamworking and the development of a collective shared mental model that will facilitate the achievement of peak performance in high-stress situations.
Use of the ZPS does not go against existing guidelines or recommendations for leading resuscitation efforts; it does, however, provide a framework for a team leader to enhance their performance during such situations. The framework uses a mnemonic called STEP UP, which is split into two phases—the preparatory phase (phase 1) and the patient care phase (phase 2)—both of which will be discussed. While the mnemonic is easy to remember, it is worth exploring its components in more depth and how they align with the theoretical framework of the ETMD.
ZPS: preparatory phase—phase 1
The first three parts of the ZPS relating to the preparation of patient care align with the pre-scene preparation phase of the ETMD (Figure 3). This phase of patient care or resuscitation (as originally intended) is concerned with planning and preparation using the abbreviation ‘STE’:
Self
One of the first sections of the ZPS is the I'M SAFE checklist, which is widely used in the aviation industry to ensure pilots are safe to fly (Table 1). In the context of healthcare, it allows a clinician to consider his or her own readiness for providing patient care. Paramedics can apply the checklist at any time before or during the shift, including before arriving at work, as they are checking the vehicle at the start of their shift or before entering the scene.
The cognitive readiness section of ‘self’, which comes next within the ZPS, incorporates concepts formulated in North America by Lauria et al (2017), who discussed strategies that can be used to improve the performance of emergency clinicians working under stress. Lauria et al (2017) proposed four key performance-enhancing psychological strategies (PEPS) in relation to providing medical care. In the ZPS, these four PEPS are represented in the shorthand of breathe, talk, see and focus (Table 2).
| B | Breathe (tactical breathing) |
| T | Talk (to self) |
| S | See (mental rehearsal) |
| F | Focus using a trigger word |
Adapted from Lauria et al (2017)
‘Breathe’ relates to performance-enhancing breathing techniques. To use this technique, square-box breathing is undertaken, which involves slow, deep inhalations and exhalations. Such techniques have been shown to benefit the performance of police, the military and surgeons, and are suggested to reduce stress and symptoms of psychological trauma in responders (Grubish et al, 2016; Willis, 2019). Techniques such as these can be used before or during a stressful event.
‘Talk’ refers to the concept of positive self-talk—a positive internal monologue used to boost performance. This can be generic as in ‘I will succeed’ or ‘I will do this’; more motivational such as ‘This person needs my help to survive and I can do it’; or specific to a certain procedure such as ‘insert the blade and sweep left, smoothly advance into the vallecula’ to facilitate effective intubation (Lauria et al, 2017; Reid et al, 2018).
‘See’ involves the use of visualisation exercises and mental practice. Previous research has shown that mental rehearsal improves the performance of technical skills in healthcare (Hall, 2002; Arora et al, 2011; Lorello et al, 2016) and may perhaps also aid relaxation (Willis, 2019).
‘Focus’ involves the development and use of a trigger word to enable a clear, focused approach to the task ahead (Lauria et al, 2017).
The ZPS then progresses beyond the team leader to consider the wider situation, including their resuscitation team, the environment and the resuscitation itself.
Team
‘Team’ highlights the benefit of assigning team roles early and appropriately where possible. For example, where only two paramedics are on scene, they must identify their roles early. When additional resources arrive, a new team forms and will behave based on a number of factors including experience, seniority, local policy or a combination of these.
Addressing this issue early should prevent later confusion and facilitate progress along the settlement pathway of the ETMD (Summers and Willis, 2010). It may also prevent common errors such as assigning an advanced task to the most junior member of the team, such as gaining intravenous access in a shutdown patient.
Environment
‘Environment’ provides a reminder to assess and modify the environment to allow safe, effective care efforts to be started on arrival at the scene. This may involve moving equipment or furniture away from the patient to create additional working space, or pre-planning through training how and where to use kit dumps or preparation areas once on scene.
ZPS: patient care phase—phase 2
Once appropriate planning has taken place, the second phase of the ZPS addresses patient care using the abbreviation ‘PUP’:
‘Patient’ concerns the phase where resuscitation or other care when applied more broadly to paramedicine begins, using the standard ‘CABCDE’ (catastrophic haemorrhage, airway, breathing, circulation, disability and exposure) primary survey to assess and manage the patient. This is the point at which patient care has the potential to distract paramedics from ensuring cohesive team-working, and may herald the start of disparities of opinion and divergence from the settlement pathway of the ETMD.
‘Update’ serves as a prompt for the team leader to share information with the other paramedic or paramedic team (if multiple crews are on scene) and ensure that team members share a mental model. This aims to address any potential disparity of opinion between clinicians (Summers and Willis, 2010). Furthermore, the team leader must be mindful to never enter a course of action that is a surprise to others on scene, which may cause a significant rift in team cohesion (Hinds, 2015). The update phase therefore allows a shared mental model to develop and should facilitate full team buy-in (Figure 3).
‘Priorities’ allows the team leader to set clear care and resuscitation goals and delineate priorities for care to the rest of the team. This allows consolidation of the shared mental model and forms a plan of action for the next steps in the resuscitation. It also provides a focus for overcoming differences of opinion between clinicians, and resolution of such disparities through creation of a clear path to be followed. It is an excellent prompt for on-scene time management and prioritising extrication and onward transport.
Tying it all together
The process described herein allows the ZPS to be applied to a patient care situation. Before arriving on scene, the paramedics individually progress through the phase 1 (S, T, E) stages of positive self-talk, and undertake self-reflection by considering the I'M SAFE checklist. They may perform breathing exercises to help calm any pre-scene anxieties. They may even talk about their stages with one another on way to the scene if they wish.
Even if the first phase is performed individually, paramedics should be discussing with each other who will do what as part of the ‘team’ component and phase 2. Doing so will not only help improve preparation before arrival on scene but may also allow differences of opinion to be minimised through communication. This might be as simple as agreeing to undertake a scene assessment, then getting back together to make a plan of action, including how to keep the environment safe.
Once the crew has arrived on scene and started patient care in line with what they agreed, they should maintain high levels of communication and provide ongoing updates to one another routinely, setting new priorities as the scene or situation changes. This will allow the crew to remain in the settlement pathway as opposed to entering a disparity of opinion.
Conclusion
The modern discipline of paramedicine requires new ideas to assist paramedics in the delivery of safe, effective care during routine and crisis situations. The synthesis of the ETMD with the ZPS facilitates a method of closing the theory-practice gap in relation to optimising personal performance and applying CRM techniques to the care of our critically ill patients.
Such tools can be used during undergraduate or postgraduate education and can provide a framework through which practitioners can maximise the quality of the care they provide, and improve both leadership and teamworking, within the paramedic profession.
Further research looking to validate tools such as these in the out-of-hospital environment will not only strengthen their position in the academic and professional communities, but may also allow for further modifications to enhance their applicability.