In this module we learned all about what can go wrong with teams in the chaos of everyday work. For many of us, the stress of teamwork might involve tight deadlines on projects, or personality conflicts between members. For our guest today, that stress is at a totally different level because he works in an environment where life and death decisions are routine. We're interviewing Dr. Jack Gucci who is a professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania which is one of the top medical facilities in the world. He's also co-director of the hospital's Lung Rescue program and one of its intensive care units. So Dr. Gucci has plenty of experience working with teams under pressure. You're about to hear Dr. Gucci talk about why some of the best teams can get off track in stressful moments and how he manages people in high pressure situations. [MUSIC] >> So I'm Jack Gucci, I'm the health systems director for heart and vascular ICU's for the University of Pennsylvania. The teams that I manage take care of cardiac surgery patients before and after their heart surgery. The sickest patients you can imagine, very acutely ill. I also manage the Penn Lung Rescue program which have a mobile ECMO program which basically is the ability to place a patient on a heart lung machine in the field at outside hospitals. This is a complex technology that only a handful of centers in the United States are doing. So the composition of the Penn Lung Rescue team, it's actually rather broad. So the mobile piece of that, so the team that goes out to the outside hospital is a transport team. So that includes a pilot if we go in a helicopter, a critical care transport nurse, so they're very highly trained ICU nurse. A paramedic and then a perfusionist, so that's a person who is trained to run the heart-lung machine, and then two physicians, who go on this team to implement the machine, and manage the patient. So, a very highly trained group of people who have to interact well as a team. So the Penn Lung Rescue mobile team comprises generally six people, each has their own individual role. There is a team leader on the field, which is the physician, so the physician directs the care, and the team of both physicians actually, implement and insert the ECMO. We have a profusionist who manages the heart lung machine, and who informs the physician team of any changes. In addition, there's a critical care nurse who helps to manage the physiology, the ventilator on the patient. And the pilot, of course, who's critical in assessing the safety of the flight, a rapid flight, landing, and also managing the weight of the equipment on that flight. So we have had instances where that person has said, we're going to leave a person back here and get picked up later, or equipment, that sort of thing. So each person has a role and if they don't fulfill their role, the outcome will be bad. [MUSIC] So a typical scenario for the physician on the Penn Lung Rescue team is, I carry a pager all day. And we're called by an outside hospital and the outside hospital will have a patient that they feel is dying basically and needs this therapy to help save their life. So you have an interaction with an outside hospital physician who desperately wants your help. So, they are pressuring you to do what they think is best, which is put the patient on your heart lung machine. Then if you agree to put that patient on you have a talk with the family of the patient, because those patients are in no condition to talk to anyone. And of course the family is under tremendous stress and wants you to help them. Once that is complete, we are on our way to the other hospital via helicopter, it's usually a very brief flight. We arrive on the scene and it's usually close to pandemonium. The ICU there is desperately trying to keep the patient alive, the patient very frequently has just finished a cardiac arrest, may have been getting CPR. So you can imagine there is a time component to this where there's a lot of pressure to get moving fast. But there's also from our side the pressure not to move so fast that you make mistakes and do the wrong thing. Some of the most extreme situations, we get there and the patient looks like they have a very high chance of dying. So we have to move quickly, which everybody on the team is trained, what their role is so it's very easy to land and within 15 minutes have the patient ready to put his device on. So those are the kind of situations that we arrive to. [MUSIC] Actually with the team we've had multiple different things that can happen. One is, for instance, even from before we get there, the transport can get changed. If the weather goes bad, then we go from flying to driving, which extends the time it takes for us to get there. In fact, in one extreme instance, I was driving into the hospital to go get the equipment and meet the helicopter, and they called me and said, the helicopter can't fly and the ambulance isn't ready and the patient was a family member of a nurse that I worked with. So you can imagine the incredible pressure with that. So what we did was reorganize the team, drove the machine in my car with part of the team. Started the process with half the team and the other half of the team met us there and on the fly kind of made decisions which saved that patient's life. Other things that can go wrong, these patients are so unstable that even with a heart-lung machine about half of them can pass away. Our survival rate is much higher than that, about three-quarters of them live so we're very proud of that. But even changing the position of the patient slightly, lowering their head of bed, slight changes in their ventilation management, all of those things can make the patient die. Before they've been put on this machine. You can have challenges putting putting this heart lung machine on. Certain patients' anatomy will make it more challenging, so that's something you have to anticipate. [MUSIC] I think in these high pressure situations almost akin to the military when you have a very high pressure situation, where time is a factor and lives are on the line, you do have to have a chain of command much like you do in the ED or the trauma bay. So ultimately you do have to have a large amount of communication so you can't have the siloed, I am the captain of the ship, I don't want to hear from anyone mentality. You have to be able to receive feedback and give feedback back in a rapid fashion. So you have to have an open mind in these situations, because if you proceed without anybody giving you feedback, you can definitely go down the wrong. You don't want to be in a situation where you did the wrong thing. Somebody saw something that you were doing wrong and was afraid to tell you. So you have to lead but you also have to be open for suggestions, feedback, and other people's opinions. That's why when you have an experienced team, even though you are leading the team if you are working with people you trust it will go well. because you can trust their feedback. To generate an environment which it's easy to make decisions and carry out this care in a systematic way. The easiest way to keep it quiet is to have protocols. So when we come into these outside environments, we're a separate team entering into another team's environment. Many institutions are not as well equipped to deal with this and that's why they're calling us. So when they see it, they kind of model our behavior, so if we ran in yelling and screaming they would do the same thing. When we walk in very quietly, very efficiently, and in a protocolized way, instituting our care, they model that, they become very quiet. It's very interesting to watch and I think that's the best way to maintain a quiet environment. If you watch any high stressed medical situation that is well run, there's two main reasons they work well, protocols. So everyone knows what they have to do without being told, and so I don't have to explain to everyone in the room every single step I'm doing and have a decision point every point, because it's done the same way every time. And one of the other ways we accomplish this is by simplifying as much as possible everything we do. Minimizing the amount of choices we have to make, so we don't have 10 different things we choose from in each instance, it's two. The last way we accomplish this is by having drills or simulations. So before we went out and did this in a field, we practiced this at our own hospital for years, and we did simulations for a mobile one. So that when we did the first one, we had already been doing it for years. It was simple, and it went very smoothly. [MUSIC] When you're working with a team and their highly passionate people and working in a highly stressful environment like that, the people that are attracted to that tend to be people who like high stress. They also tend to be a little bit emotional and sometimes that can be to the detriment of acute situations and decision making. So there's number of ways to harness that. One is, especially if you are the leader and there is another co leader who is very emotional and is distracting the team, interrupting the team with their emotional outbursts. Part of the way to handle that is to have discussions outside of that situation, either before or in a debriefing afterwards, alone with that person to explain to them what's going on. The other piece is if that person understands that everyone else in the room has as much emotional input and buy into the same outcome, they tend to calm down. Those people tend to react the worst when they think they're the only ones who care about that outcome. So reassurance and feedback are the two keys to that. [MUSIC] So to debrief or follow up on individual patient issues, operations issues, or events, we have a couple of mechanisms. One is we have a debrief after each event. So, we have basically a group chat on a telephone, we text out the number, we have a group chat. And everybody brings up issues that they think are important. I think, as a team leader, it's also very important to recognize a certain team individuals may not work well in those types of situations, whether they're shy, they don't feel comfortable getting feedback. It may be something that they feel will insult someone else in that debrief session. So you have to kind of have a sense of who those people are, if there was an event, follow up individually with people one on one. And then the other way we do is a regularly scheduled operations meeting where we review multiple different types of cases, particularly things that went not well. But if things go well also I think you have to review those. So the best thing about having a regularly scheduled meeting is people have time to think over what happened rather than the debrief right after the event, which leaves no time. People are just bringing up things that went wrong. People also come with solutions to those operations meetings. [MUSIC] As a leader, you can create a situation especially as a strong leader where people don't feel comfortable giving you feedback. Which can be devastating because it can really cripple you as a leader and in the program. So you have to, even though it may hurt you personally and it doesn't feel good at the time, you have to immediately swallow your instinct and give very positive feedback openly. That's very good I need to hear that. Those kind of reinforcements and then say, I would love to hear more about those types of things in the future. I need that to improve as a leader or as a team member myself. And if you don't do that as a strong leader you are really inhibiting your ability to grow. I say this to my children and I say this to the team members, you don't learn as much from your success as you do your failures. So I think as a leader if somebody tells you about your failures, whether they are significant or insignificant you also have to reflect on them. If you immediately dismiss them, you are also not doing anyone a favor. So frequently if somebody gives me something that they feel I need to work on or something that I failed in, I will discuss it with multiple people myself to say okay was this legitimate? How can we can improve on this? What should do in the future? And I've gone to those people and said I need to hear back from you again if this happens again or if there's something else. And I think that's one of the most important things you can do because it really builds a lot of trust in the team if you're vulnerable. [MUSIC] So to create a team that is able to give feedback to each other, is the most important thing is to depersonalize it. So to stress that everyone there, and everyone there does care very passionately about their job. They are so passionate about their job that they're doing it with me on nights and weekends. They're literally leaving their nice, warm home on a winter day, coming and flying to an outside hospital in the middle of the night. So you can't imagine a more dedicated team. And so part of fostering that sense of trust and able to give feedback without hurting people's feelings, because these people are passionate and emotional is to depersonalizing it by turning many of these things, which virtually 100% of them are systems issues. So if a person made a mistake in judgement, it generally is a systems issue based on the protocol. It's not because they made a mistake and wanted to do their own thing. So that's why we have so many protocols but the other piece is to not make it about the person make it about the system. So if you're asking somebody to give their own self assessment, the first thing you do is give your own self assessment. And maybe even exaggerate some of the things that you did that could have been better. I could have done this quicker, I could have brought this, I had wasted emotions with this so it could have been more efficient. Those types of things so that the other people feel like they can open up. [MUSIC] I think, when I manage a team, there is a certain amount of background noise. And to work efficiently as a team, you have to understand that there's teams that work well and then when the team is not working well because they are unhappy, they're over stressed, you have to be able to recognize that. So there's a couple signals that you can look at. One for me is the amount of complaints, and there's a certain amount of background noise you hear on a regular basis. And if you hear either zero background noise, kind of like when your kids are playing in the next room and you hear nothing, that's a problem. Or if there's a lot of yelling and screaming, that's a problem too. Now those are the extremes obviously but you have to come have your ear to the ground with that. The other piece is when you start to have breakdowns in standard operating procedures. So people start making mistakes that they wouldn't normally make, and lastly, if people start to not show up to work. So if people start to get sick more than they used to, whether they're sick or not, that's something you have to kind think, is this somebody who's trying to escape form the team because we're over stressing this team?