David Hakim is an anaesthetist (anesthesiologist) who lives, works and chases race cars in Canada. He gave one of the talks at last year's ICMS annual general congress in Indianapolis. The topic he chose was one that he has spent some time exploring in order to try to streamline how motorsport rescue and safety is practiced by the team that he works with. 

This exploration led him to learning more about how we think and behave in certain situations and, more importantly, what we can do about it to get the best outcomes.

Here's a breakdown of what we get into. It isn't everything that you need to know, so check out the references at the end for further reading.

1) What is Crew Resource Management?

There are several varieties of definition, but essentially it boils down to developing ways of doing things (processes, procedures, strategies) that minimise error potential and enhance the capacity for the individuals involved to best use their knowledge, skills and immediately available resources to achieve the best outcome possible for the situation.

It originated from the aeronautical industry as a way of trying to understand why crashes and mishaps occurred and then identifying strategies to prevent their recurrence. A lot of the language and characteristics of the CRM process have been ported over to various areas of medicine, with a number of groups and individuals working to figure out how best to apply these lessons to patient care.

Crew Resource Management (CRM) is also known by several different names including Crisis Resource Management and Cockpit Resource Management. However, direct extrapolation from aeronautics to another industry is not always valid and there often needs to be some tailoring of practice. So the term is often altered to fit and in motorsport medicine, it has been called Race Resource Management.

Regardless of the name, the key element of CRM is careful analysis of processes to identify the strengths and weaknesses leading to the developments of a strategy that promotes the best outcome followed by ongoing assessment to ensure that the target outcomes are being achieved and evolving as new information comes to light. It is an organic process.

2) Why should we care about CRM?

In general, when things are going smoothly, the stress levels are low and we feel like we are on top of our game. However, that time that we are really tested is when things are deviating from the intended trajectory. This is when a situation can feel like either a challenge or a threat, depending upon whether we feel that we have the requisite knowledge, skills and ability to deal with it. If any of these three components fail, the chance of error and therefore a bad outcome rises.

3) Knowledge and skills

These two components are what we spend most of our time and effort trying to improve. So if we are smart and have the right skills, why should anything go wrong? 

When we are calm, it is fairly easy to assess the situation, choose the correct course of action and act. In a crisis, the pressure is up and something akin to the fight or flight reflex may kick in. If we are not thinking straight, our approach to the issues confronting us may become unbalanced, leading us to apply our knowledge and skills inadequately or inappropriately or not at all.

Both System I and System II processes are useful and have their benefits and downsides. Understanding how they work and how we work with them can help us to refine how we behave when the pressure is on.

"Use your attention wisely"

4) Situational awareness

Simply put, this is our ability to remain aware of or environment and how it might evolve. 

A football player will be aware of roughly where their team mates and opponents are, how the ball is moving, the direction of play and where the goal is. Similarly, for a race track incident, there may be any number of items to remain aware of, such as the location of the incident, whether the yellow flags or safety car are deployed, is the car on fire, where are the rest of the race cars, what are the clinical priorities and whether it's more appropriate to go to the circuit medical centre or straight to the receiving trauma hospital. 

Under pressure, there is the potential to develop tunnel vision, either cognitively or literally. This can be due to:
  • Cognitive overload
  • Environmental overload
  • Communication overload
The result is becoming overwhelmed, which may lead us to being unable to effectively or appropriately apply our knowledge and skills.

5) Resolution

Cognitive and behavioural psychology

Understanding the concepts behind how we think and behave helps us to develop strategies to mitigate the error prone elements. There are multiple resource available to delve in here. Go check out the reference list below.

Cognitive off-loading
  • Pre-event planning and Standard Operating Procedures (SOPs) - How will we approach an incident? Role allocation. Exit strategy.
  • Checklists - These help to reduce the cognitive burden of certain activities, but they need care in their development. Go listen to this podcast: "Checklists" on Phemcast - https://phemcast.co.uk/2018/02/09/episode-27-checklists/
  • Rally points - Regular planned breaks in activity to perform a self and/or team catch up so that it is clear what the priorities are, what the intended targets are, how to get there and whether they are being reached.
  • Leadership and followership
Stress inoculation practice 
  • Sim training really helps here. 
  • Debriefing is critical and is where most of the learning is made explicit and concrete. 
  • There should be specific, achievable objectives. 
  • Start gently and build up as abilities and confidence grows.
  • Practice should be deliberate. 
  • Mixed team and mixed skill training not only improves knowledge and skills but also improves team cohesiveness.

The podcast

The intro music clip is from Music For Pleasure - The Human Factor (7'' Version)

The slides

(These are the slides from David's talk at the ICMS Congress)

Crisis m anagement final from DavidHakim83

References and resources
Finally, Dr Andy Buck has a whole website devoted to clinical CRM and human factors strategies called Resus Room Management - http://resusroom.mx/