Seeing multiple EDs across the province closing represents nothing short of a crisis.

These EDs and ICUs were built for a reason and to imagine we are now closing them despite rising volumes and demands leaves me speechless.

Here's a 🧵 on crisis management
1/
In my job as a trauma physician, I regularly face crises and manage uncertainty.

There are several key principles we teach in crisis management & decision making that would be helpful to apply to our HC system. I’ll outline 4 in the thread below.

2/
1. Crisis declaration: The team leader must declare that an emergency/crisis is occurring. Sounds simple and intuitive but yet I have yet to hear this from key decision makers. When we’re faced with a critically injured patient, the team lead states something to the effect
3/
“this patient is critically injured with ongoing hemorrhaging causing hypotension”.

A declaration that our healthcare system is in crisis is essential. Everyone must have a shared mental model of what is happening, effectively ensure we're all on the same page.

4/
Further actions are virtually impossible without this because people will not understand key priorities. If we look back to the early days of #COVID, we all knew where our healthcare leaders stood with priorities…under all circumstances the goal was to preserve capacity in

5/
the EDs and ICUs…I don’t even know what’s happening anymore.

6/
2.Be clear & transparent with communication. It’s entirely possible that I won’t know the cause initially for why the patient is unstable. So I will explicitly say “The patient is unstable, I’m not sure why".

7/
Then ask my team..."What am I missing?”.

This engages the rest of our team to speak up. In our HC system right now, its ok for leaders not to understand all the nuances leading to our crisis, but it is essential to open lines of communication. Listen and learn.

8/
There will be key insights that are gleaned from frontline clinicians and patients. Some things can't be addressed immediately but other elements can easily be actioned on.

9/
3. Become hyperfocused on 2-3 key priorities. This is usually set by the team leader.

When an injured patient is bleeding, we have typically 3 priorities:
1) stop the bleeding
2) replace blood loss and
3) fix other physiologic abnormalities

10/
We don’t worry about anything but the immediate threats to life.

The same should be done in our healthcare system.

There certainly are lots of problems but people will face significant harm with ED and ICU closures. This has to be the near term priority over all else.

11/
4.Make an initial first step that prioritizes safety, enough to buy yourself time to consider other options and analyze the problem more deeply. We pre-script our first 5 minutes or few steps. It becomes automatic.

12/
Once the patient stabilizes, after the blood pressure stabilizes, the patient has been intubated then we take a breath.

We discuss, regroup and update our plan.

We’ve bought ourselves a few moments to thinking more thoroughly and engage the entire team for our next steps

13/
In HC …the next steps should likely be to keep all EDs and ICUs open. What are the key steps to make that happen?

Staffing is likely a keystone issue. Maybe there’s 1-2 other components. Identify those. Now!

14/
Once that is happening then we can collectively look more deeply at the rest of the system. But if people are facing harm or dying because they can’t access care under life threatening circumstances

15/
then we’re certainly not in a position to be able to manage the elective & non-urgent aspects of patient care.

Hard to manage hypertension or replace joints when we can't help those who are near death.

16/
So, in summary:
1. declare the crisis
2. use transparent communication
3. hyperfocus on 2-3 priorities
4. Make a safe & quick first decision to buy time

We can't afford to wait.

END

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More from @petrosoniak

Jul 21
As a fellow emerg doc, I'm extremely disappointed to see this inaccurate focus on COVID related illness as the main cause for incr ED wait times and staff shortages.

Rather the link to COVID is that it exposed a system that has always been non functional, but now just more so.🧵
This was an opportunity in a national magazine to help the public appreciate the current state of healthcare and the massive inefficiencies in the system...unfortunately this does little to advance the public understanding.

Here's a thread outlining the complexities.🧵

2/
At our large, academic centre and in speaking with other colleagues across the province, the link between COVID & ED waits 3/
Read 15 tweets
May 26
We keep hearing how our healthcare system is collapsing (which it is). But that does nothing to improve our understanding.

Let’s use a hypothetical emergency department visit to highlight the disaster that is happening every day around the country.

Here’s a thread 🧵:
2/ Imagine you have abdominal pain. You make the decision to go emerg. You arrive by car and walk up to the doors.

You’re greeted by security.

Maybe you might find this uninviting for a hospital.

Well, these security guards are unfortunately necessary.
3/ They’ve escorted out 3 people in 12hrs for assaulting HCWs.

Those HCWs are still at work, b/c there’s no one to replace them. They’ve prevented an individual with a weapon from entering the ED and harming those inside. I wish I could say the hospital is always a safe place.
Read 25 tweets
May 9
People ask me how is the emergency department these days, is there much #COVID19 anymore?

My observations below in a short🧵

TL/DR = the healthcare system is a disaster and it will be years before it improves...so buckle up.

1/
The short answer in my experience/observation is, no we're not overwhelmed with #covid19 patients requiring ICU level care in the hospitals.

But...that oversimplifies the current state. Let's look at it from the hospital, clinician and patient/family perspective...

2/
At the system level

Healthcare leadership, running large multi-million dollar organizations have spent the past 2.5yrs devoting most of their effort towards managing a crisis of epic proportions.

3/
Read 15 tweets
May 5
If you’re a leader and responsible for decision making in your organization, understanding the Cynefin framework is an absolute must.

Leadership requires modification based on the situation.

Here’s a brief 🧵 contextualized within #resuscitation & #healthcare
1/
Created by @snowded this 4 domain framework (5 with disorder) provides decision makers & leaders with a high-level yet practical approach to decision making by appraising the current state & developing an appropriate strategy

Great overview here.
2/
hbr.org/2007/11/a-lead…
Importantly decision making/leadership approaches are dynamic and are adjusted for the current context

Leaders "will need to know when to share power and when to wield it alone, when to look to the wisdom of the group and when to take their own counsel." - Snowden & Boone

3/
Read 16 tweets
Apr 16, 2021
THREAD: Here’s a bit of a systems take on what we’re seeing in the Ontario healthcare system. #covid19

A system that is under stress behaves differently than one that is working efficiently.
1/
2/ The "limits to success" archetype from systems thinking is helpful here...to improve performance, increase effort but theres a limit eventually... then resistance occurs and system function declines...i.e. what's happening right now in Ontario

availagility.co.uk/2011/03/08/kan…
3/ #Ontario ICU/hospital capacity isn’t so straightforward. Its not like an airplane w/ 200 seats and once you hit 200, there’s no more space. That's a simple system…that has a clearly defined capacity...The solution...build bigger airplanes!
Read 17 tweets
Mar 31, 2021
THREAD: Some thoughts on the 3rd wave...

I'll be completely honest, I didn't think 3rd wave was a thing a few wks ago...and I work in the emergency dept. Full disclosure, it now appears I was very wrong (for anyone who knows me...i hate being wrong...)
I heard @ASPphysician @IrfanDhalla @TorontoIDDoc among many others warning us but despite early signs I figured that vaccines will protect elderly. I assumed that #covid19 may circulate higher among young people but that case numbers would be inconsequential

2/
I figured nicer weather would allow many to socialize outside and honestly even if ppl chose to socialize inside, as long as young/healthy, even if they get #covid19 they'll be fine

I, like many, was just done with the pandemic. We have vaccines...we can see the light

3/
Read 10 tweets

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