In a dangerous field like heart surgery, safety is a concept that demands continuous clarification. What we describe as optimal safety performance varies depending on whether it is given by an individual or a team. An individual that is being mindful has better chances of remaining safe from being harmed or causing harm. For example, just last week I tripped in a hallway that was normally uncluttered because I fail to notice a trip hazard on the ground. On the other hand, I almost never trip in the operating room (OR). That’s because I’m more mindful of power cords, equipment, water spills and other things on the floor than I would be in a hospital hallway. On a cardiac surgery team, remaining mindful is necessary but not sufficient for safety. A team that achieves safety in the face of major hazards is when its members possess something called ‘heed.’ I’ve been reading the safety literature for years and convinced that heed is the word that crystalizes the most important ingredient of a high performance team.
Heed is a term that seems simpler than it is. Webster’s dictionary describes it as “to pay careful attention to or take notice of,” but it takes examples to really understand what it means. Consider the clown that trips on purpose, as part of his act. He does not trip mindlessly. First, he draws attention to himself so that everyone is watching. Then he exaggerates the impact of tripping, heedful of how his acts amuse the audience. In a different context, a high-performance team achieves safety by heedful interactions between different actors. The best example is the opening scene of parts I and II of the movie “Top Gun.” Both movies start out with the Kenny Loggins song “Danger Zone” played to a scene of intense sound, hot exhaust, grease, seawater, stiff wind, and flights taking off and landing on a runway that rocks with the seas. Workers in colored shirts coordinate the intense activity: yellow shirts are safety directors, green shirts are deck maintenance, blue shirts are responsible for elevators and tractors, purple shirts (“grapes”) handle the jet fuel (“grape juice”), and the unlucky red shirts given the job of handling explosive munitions. I watched top gun thirty-five years ago thinking the “danger zone” was referring to the far-away battlefield where pilots engage their strategic target. Now I realize that the song was referring to the runway that those supersonic jets were taking off and landing. But for the heed shared among those in colored shirts, a runway the size of a football field would be turned into a macabre ballet of steel, explosives, gas, and human flesh.
It almost seems impossible for that runway to handle its required volume of flights safely, every day, with the incidence of jet crashes—0.2 aircraft lost per million flights—that is around the same as most commercial airports worldwide. A crew doesn’t attain this level of safety performance just by doing what they’re told. They become resilient by taking active responsibility for their own behavior, developing and sharing first-rate information about their jobs. They make good use of their empowerment, based on the well-earned trust of their superiors, to shape effective solutions to lethal problems. Those types of social behaviors set the groundwork for heedful interactions, even if few know it by the term “heed”. It is heed that guides a team member to contribute to the collective mind of the team through the perfect mix of speaking up and listening up. Being heedful as part of a group, not mindful or careful as an individual, is how mistakes are eliminated or prevented from turning into adverse events.
There is a reason I am emphasizing an awkward word like heed. Linguistic theory suggests there is a relationship between the words you know and the way you perceive the world. For instance, Eskimo people have a specialized vocabulary to describe the many variations of sea ice that they interact with while hunting or sailing and that makes them more efficient than others at handling their dangers. The Oscar winning movie “Arrival” (2016) pushed this theory to the extreme in its story of aliens who arrive on Earth speaking an advanced language that viewed time as circular, not linear as a human. Once the human linguist expert (played by Amy Adams) learned their language, her own perception of time shifted from linear to circular and that gave her the power to see into the future. At the other extreme, George Orwell’s book 1984 proposed a dystopian language called Newspeak that limited the number of words the population was able to use as a political weapon to control their thoughts (and actions). If the words we know influence our thoughts and actions, it is telling that the word heed is rarely included in medical culture. My long-term goal is to change surgical culture through high performance teamwork. It is the word “heed” that gives me a goalpost to measure progress.
No team can be heedful without certain prerequisites. First and foremost, the lead surgeon must have advanced technical and leadership skills. There must be a first assistant who plays an assertive role during the case, exerting a positive influence on the rest of the OR team’s performance. The staff must be experienced and prepared for any potential changes in the game plan; they must be aware of all the things that could go wrong and have the flexibility to adjust their roles accordingly. Anesthesiologists must be technically skilled, knowledgeable, and assertive about hemodynamic problems and potential solutions. Anesthetists and perfusionists should be attentive to any ongoing problems that might come up, when patients are off- and on-pump (heart lung machine), respectively. Everyone in the room must have the advanced expertise to deal with these problems quickly and effectively.
Mercy-Lourdes, the community hospital in Paducah, Kentucky where I work, is blessed with an abundance of prerequisites. Our anesthesiologists are particularly gifted at performing advanced echo exams with a probe through the esophagus, called a TEE. One has a particular knack for performing the TEE exam exactly when its information is needed the most. For example, he recently noticed air bubbles in a patient’s left ventricle just when the patient was showing evidence of unilateral brain oxygen desaturation. On another occasion, a lot of blood appeared in the operative field. By obtaining a real time exam with the TEE probe, he noticed blood flow across an improperly placed aortic cross-clamp; I repositioned the clamp, immediately resolving the problem. Others have consistently confirmed the anatomy of the descending aorta when femoral artery cannulation and perfusion issues arise.
We can rely on prerequisites alone—the knowledge and skills of the surgeon, anesthesiologist and the array of practices memorized by everyone in the room—to succeed in standard cases. However, things change the moment we decide to take on cases higher than average risk (greater than 5-10% chance of mortality after surgery). These cases are like climbing Mt Everest. Both are extremely demanding, which is why most people are averse to even consider such an idea. Accepting their challenge is optional, but succeeding is not. They demand more out of a team by posing something called an “ill-defined problem.” The solution is often ambiguous and not always clear at the outset. Understanding how to proceed requires collective wisdom that comes from heedful interrelating: each team member contributes their unique skillset to the effort while remaining subordinate to the team’s overall objectives. These objectives are defined by the surgeon and modified by feedback from the team. For instance, a heedful perfusionist operates the heart lung machine with the surgeon’s objective in mind: to facilitate an efficient and safe surgical case. One who becomes sidetracked by an alternate set of goals of running the machine—goals not prioritized by the surgeon—isn’t being heedful.
A great example of heedful interrelating at our hospital was when two specialists, an anesthesiologist and an anesthetist, brought a critically-ill patient back to the OR a few months ago for bleeding. The patient was barely alive upon transferal to the OR table. As the surgeon, I was distressed as the one accountable for this horrible complication. The anesthesiologist and anesthetist were constantly speaking out loud to each other in the room about the myriad problems they uncovered and their intentions to address them. I acknowledged their communications by letting them know their transparency was greatly reassuring; it allowed me to put my full focus and energies on the difficult technical task of relieving the pressure created by blood clots surrounding the heart. As a team, we leaned heavily on our mutual feedback to guide that case towards success and the patient back to life.
Other examples of heedful interrelating include a surgical technician whose only training in how to read an EKG was listening to our past descriptions of an abnormality called “ST elevations” in other patients, and what risks this symptom entailed. Based on this prior experience, he was the only one who noticed these ominous ST changes in a patient with a critical blockage in the left main coronary artery—everyone else was distracted by their operative routines. After he brought this to our attention, we changed our focus immediately. In addition, our service line director heard us describe the struggles of using a portable fluoroscopy machine (C-arm) to complete various catheter-based procedures in a standard OR. She made the executive decision to assign us to a specially designed hybrid OR that has embedded fluoro equipment to facilitate these procedures. The initial change was awkward—change always is—but we now recognize the invaluable impact of that heedful decision.
Problems happen during high risk cardiac surgery that can be too complex for one person to understand. When such problems happen, a standard team full of talented individuals acting individually can lose situational awareness and that often ends tragically for the patient. High performance teams avoid this by building a collective mind that is far more insightful than any one individual. This requires the well developed social skills that define heedful interrelations – cooperation, collaboration, concise and effective communication. Without those skills and the trust they create, comprehension of these risky problems can only happen one brain at a time. That’s never enough for high risk.
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