I'm Ashley Pavlik, I'm a resident at the University of Michigan. And I've been asked to share with you, a story of good entrustment, from our attendings. So about six months ago, it was towards the beginning of my second year as a resident. A patient came into one of our resus bays with a LUCAS compression device. This patient had had a cardiac arrest. And I went to the head of the bed because that was the position I was used to being in to manage the airway. It turns out the patient already had an airway. So I started drifting down towards the foot of the bed. sort of looking at my attending, not clear of what, exactly, role I should be playing in this resuscitation. My attending then turns to everyone in the room. And says, this is Dr. Pavlik, she will be running this resuscitation, all of your orders will come from her. And so I said, okay, and I sort of looked at her, and she looked at me, and I looked at her. And she said when was the last time the patient got Epinephrine? And I said, oh right. And so I asked, I asked the EMS providers and she was due another milligram of Epinephrine. So I shouted it out and then the, the code went on. At one point she said to me, you know, treat me as if I'm your resident. What, what would you like me to do to be helpful? And then, she suggested various things. Such as would you like me to put the ultrasound on the patient's chest and look for cardiac activity. I said yes. And she at various points also said, what about, what do you think about trying Narcan? What do you think about trying this or that? She had created the illusion for everyone in the room that I was running the code. And also, created it for me so that I felt like I was in charge. But really she was there the whole time supporting me throughout it. About 48 hours later, there was a similar situation with an elderly gentlemen. Again, coming in on the LUCAS Compression device after a cardiac arrest. And in this particular scenario, the attending was present and helped me put in the airway. And then another critical patient came in. An ectopic pregnancy. So the attending had to step out briefly. And during that time I think the. That we all expected that we wouldn't get a pulse back on this patient. But we did. And I hadn't been in that situation a whole lot of times. And so, I wasn't sure all of the things that we then needed to do. So between the nurses and me looking things up and just remembering things. We were able to figure it out. But that was a situation where I really felt like I didn't have the, the supervision and the guidance that I would have liked to have. Fortunately because of the previous example, I, I knew a lot of the things that I was supposed to do because I had been entrusted previously. But there were still some things that I felt like I needed more help with. So I've been asked to share a couple of other examples of when perhaps there was not the best entrustment. One occurred, in the beginning of my second year. We had a patient came, come in who had a, what we then found out was a head bleed. She came in with a headache and she was vomiting. And very quickly she decompensated so she was degrading down. Was becoming less and less responsive. So we knew we had to get an airway immediately. So, I was present in the room. I prepared everything. My attending was standing next to me. And, importantly, I think this was a new attending. She had only been an attending for about six months or so and from a different institution also. And so, I tried and the, the ET tube that I was using was too large because my position was good, but it wasn't passing. And so, I turned to one of my senior colleagues. Another resident who was a year ahead of me and asked for a larger tube. And then, the attending stepped in and said to the senior colleague, why don't you do it? And so, I looked at the senior colleague and he looked at me and he went and he eventually got it. I think he got two tries. But I was upset. And this attendant had known me fairly well and could read me and just tell that I was upset. And said afterwards we should debrief about that. And I said to her, well I feel like I should have gotten another chance. I know that it was urgent, but the patient was stating fine and I felt like I had enough time to try with another ET tube. To which which she said to me, I'm really sorry about that. At my institution, everyone only got one chance, and I didn't know that here that's not sort of the norm. And in addition she said, and you know, I'm a new attending, so I was nervous too. Another example from this past year is was I was working with an attending on a patient who had fallen, an elderly patient. And so, I went in and assessed her and we did a CT scan of her head and her neck and this was the plan that I present with the attending. Because I didn't find anything else on my initial trauma survey anything else to scan. A couple of hours later we were getting ready to send her to the floor and I went through and examined her again. And I found that she was tender in her left upper quadrant area. And so, I, I thought that she would probably be fine but it made me a little bit nervous. Because she wasn't tender before and we hadn't really evaluated that. So I went back to the attending and I said you know, she's having some tenderness in her left upper quadrant. Do you think maybe we should add on another CT scan? Do you think we should scan her abdomen, in case she, she hit something there? And, he said to me, well, I would've done that three hours ago. And I said, well, okay, then I'll put the order in. But, I'm, I remember thinking to myself. If you wanted to do it three hours ago, why didn't, when I brought up my plan why wouldn't you tell me that. And why wouldn't we have a discussion about it then? Because I feel like, when, I feel like plans go both ways. So when an attending wants me to do something that I didn't think of or don't especially want to do, regardless, that then becomes the plan. I'd sign out or when I'm calling a consultant or whatever, that is our team's plan. And I think it goes the other way too. If I come up with a, with a plan and the attending, you know, maybe wanted to do something else but agrees to my plan, the way that I wanted to do it. I don't think you get to say hours later to me or to anyone else, you know, we should have done it a different way. Because the time to come up with the plan is when we're initially talking about it. Another example of when perhaps the entrustment wasn't the greatest was a new attending at one of our sites. I was presenting to her and the triage note had said exertional shortness of breath. When I went in to talk to the patient, the patient had the flu, had all of the symptoms of it, sounded pretty classic. So I made a plan for the flu. Fluid rescessitation things like that supportive care. My attending after I gave my presentation said. Well I think we should do a D-dimer and a couple of other things, why don't you order that? And in my head, a D-dimer, you really only do if you're willing to do a CT scan, if the D-dimer is positive. And so, we're usually hesitant to do that unless we would be willing to CT scan them. And I was. I remember it because it's one of the first times that I really went back and forth with an attending. And I said, you know, I really don't think she has a pulmonary embolism, this really sounds very much like the flu. I don't think we should send the D-dimer. And the attending said well, I think we should send it. And the attending was looking at the triage note that said exertional shortness of breath. And hadn't really, perhaps my presentation hadn't sunk in as much about what I actually saw when I evaluated the patient. To her credit though she did go and see the patient. And it was towards the end of her shift because they were leaving before we were going to leave. And she came back and found me even after she had signed out and said to me. I went and saw that patient and I agree with you. I, I think this is the flu and so I've cancelled the D-dimer, but I just wanted to let you know that we're going to do what, what you said in your plan. I think that was a good plan. >> So I find those videos quite interesting. I particularly like Ashley's perspective on this, and Josh as well. I find it very helpful to get a sense of what the residents or trainees are thinking about. I'm now going to ask you to go to the discussion forum. And I want you to, to think about, what does entrustment and autonomy look like in your environment? And specifically, what are some of the factors that effect the amount of autonomy that you give you're learners. So when you give them a lot of autonomy, what is it that allows you to do that? When you give them less autonomy, what is it that causes you to approach and to be more supervisory in your care. And so I want you to think about those things and note them, also look at other people's comments. And let's start as a discussion around this because I find it's a really interesting topic. And in the end it helps us to understand where we stand on autonomy. And it, it helps to understand how we can give more entrustment to the learners that we're training.
