Clinical Editor's Corner: Kern

Ten Tips for a Crisis: Lessons From a Soldier for the Cath Lab

Morton J. Kern, MD, MSCAI, FACC, FAHA

Clinical Editor; Chief of Medicine, Long Beach VA Medical Center, Long Beach, California; Associate Chief Cardiology, University of California, Irvine Medical Center, Orange, California 

Morton J. Kern, MD, MSCAI, FACC, FAHA

Clinical Editor; Chief of Medicine, Long Beach VA Medical Center, Long Beach, California; Associate Chief Cardiology, University of California, Irvine Medical Center, Orange, California 

There are, unfortunately, few uplifting articles on how to live and work in the time of COVID-19. As we prepare for battle with this terrible disease, our cath lab staff is backstopping other areas in the hospital while at the same time preparing the lab to manage a highly contagious and dangerous pathogen. Feelings of anxiety and fear are unavoidable. 

I was delighted and inspired after reading a wonderful article written by Lieutenant General (U.S. Army Retired) Mark Hertling, DBA, who assembled his “Ten tips for crisis – lessons from a soldier”1 after speaking with one of his former physician leader mentees (now an emergency department physician) who is deeply engaged in her work during this crisis. Drawing from his experience, General Hertling highlighted 10 important tips for military leaders during a time of crisis, such as a war. As we in medicine are now at war with COVID, these tips would be well received and certainly strengthen our resolve during dark days to come.  

I wrote to General Hertling (Figures 1-2) to tell him how much I enjoyed his 10 tips and he gave me permission to paraphrase them here.

1. Find a battle buddy. The U.S. Army’s basic training pairs new recruits, forming battle buddies. In the cath lab, we should be each other’s battle buddies. We are in this together. As part of our personal and professional dynamics, we must form teams providing mutual support, which will be especially important for some of the critical situations we are going to face. Like army battle buddies, we too must depend on one another to keep us out of trouble, to keep up our spirits, and help us all to do the right thing and do our duty for our patients. Having a battle buddy not only applies to the front-line cath lab team, but also to our directors, administrators, CMOs, and even the CEO. These are tough times, so find a battle buddy.

2. Prepare for the worst and hope for the best. It is often thought that things cannot get worse. We think we have thought of everything and that no unexpected adverse situations will take place. Of course, this is not true. Is it inconceivable that the electricity would short out? Or the x-ray machine would go down in the middle of a COVID case? We may run out of personal protective equipment (PPE). There are a host of situations and unforeseen events that we hope never happen. However, we must plan for them in case they do. We should be prepared, or even overprepared, for the worst.  Anticipate needing extra equipment, additional or backup team members, more disposable supplies, and PPE. Consider the worst thing that could happen and then make a plan to deal with it.  

3. Get everyone into the fight. During the COVID surge, we likely will not be able to cover all the medical obligations in our hospital. We must enlist the aid of all of our colleagues, apply all of our brainpower, and use all of our teams to help bring relief to those who are working and caring for the sick. We must look across the organization and perhaps even our community to seek help to lighten the load of the overworked.

4. Fatigue makes cowards of us all. During any crisis, lack of sleep and emotional strain and stress, particularly during 12-hour shifts that may be assigned to some of our colleagues from the cath lab, will challenge our inner resources more than any prior event in our medical career. Leaders must implement rest cycles, team rotations, and days away from the hospital even when all hands are on deck. We will have to institute flexible scheduling with reduced shifts and/or timeframes, if possible. Failing to plan for human fatigue and error will cause the eventual breakdown of order and produce more harm than good. As General Hertling recommends, “take a break; do all you can do to maintain a modicum of balance and get away for a while.” 

5. Take time to huddle. Clear communication is always important, but never more so than in a crisis. Recall those times during cardiac arrest resuscitation ‘code blues’ when the communication was muddled or fragmented; actions break down and chaos ensues.  Now think of those times when the code leader clearly identified the jobs of the code team members and their functions, all smoothly working as a unit and held on task by clear communication. A huddle (gathering or meeting) at the start of the day is one way to set the situational tone, pass information to team members, look each other in the eye, and say that we’re all in this together. It is important for the leaders, both in and out of the lab, including those newly designated to work in other areas of their hospital, to be communicative to your team members in both formal and informal ways.

6. This ain’t peacetime. We now live in a time when it is no longer “business as usual.” We are fighting COVID with the only weapons we have available: social distancing, mask wearing, disinfecting surfaces, and handwashing. Eventually, we will have a vaccine as our best weapon to defeat the pandemic. But until then, we have to accept the fact that for a period of time, we will be behind the contagion curve. Most leaders understand this and support those around us who do not. It is well stated: “This ain’t peacetime”.   

7. Force adaptation; don’t wait until things are over to adjust. It is time for us to get in front of the curve, be proactive, and anticipate problems. It is inevitable that in the crisis, daily procedures may crack under pressure, or that other routines cannot stand up to the increased pace and volume of patient care, resulting in bad outcomes. It is important to identify a bad practice or inefficient method, and make a rapid adjustment to find a better way to do something. Once we see failure in process, we need to address it and fix it, pronto. The faster we can adapt, the better things will be going forward.  

8. Talking ain’t fighting. Critical situations in the cath lab or anywhere else require immediate action. During crisis events, team members must pass information clearly and quickly. One of my favorite teachings for best communication is to use “brevity, clarity, and (if possible) wit”. In addition, using feedback communication loops as we are taught in the lab should serve us well. “Explain when you can, but act when you must”, embodies the “talking ain’t fighting” concept. Remember we can discuss the details at length after we have accomplished the mission.

9. Cherish your teams. Most U.S. hospitals, and cath labs in particular, are not meant to handle mass casualties that overwhelm our medical resources and our abilities to care for the dying. Managing the emotional toll that many of us will experience will be a new challenge. When we see our community falling ill, we must remember that we will need empathy, humility, and mutual understanding with validation for our teams. We find ways to turn mistakes into learning opportunities. We must remember to be human and find ways to forgive, improve, and provide memories that our team can look back on. Praise and cherish our teams.

10. Leaders don’t have the right to have a bad day. In the army, new assignments are given and accepted as part of the job and not questioned, whether good or bad.  Frustration is inevitable. Part of the leader’s job is to communicate the mission, remind us that despite our disappointment that we must gather our resources, both inner and outer, “unpack our equipment and return to the battle”. Co-workers, like soldiers, are looking at you to lead during the crisis. As General Hertlig says, “leaders do not have the right to have a bad day”. He did not mean you could not be frustrated or disappointed or emotional or even angry. He meant we could not show it when others were depending on us. That is one of the toughest things about leading during crisis. Leaders have to be ready to lead.  

I am looking forward to having a longer conversation with General Hertling one day and having the chance to share with him how our teams did during the crisis. Until then, General Hertling, you have my appreciation for a job well done. 

Disclosures: Dr. Morton Kern reports he is a consultant for Abiomed, Abbott Vascular, Philips Volcano, ACIST Medical, Opsens Inc., and Heartflow Inc. 

Dr. Kern can be contacted at mortonkern2007@gmail.com.

On Twitter: @drmortkern

References
  1. Hertling M. Ten tips for a crisis: lessons from a soldier. Journal of Hospital Medicine. 2020 Society of Hospital Medicine. doi 10.12788/jhm.3424; Published online April 2020.