Are you looking for the next big thing in resuscitation? Are you seeking the next miracle drug, technique, algorithm that will save your patient?
Of course you are.
You are reading the St.Emlyn’s blog, or one of the many other awesome #FOAMed resources out there on the web. You may even be attending the greatest conference in the world (SMACCGold) worrying that everyone else on the planet is into ECMO, whilst you are just ECNO. We are just like our audience….. we love the new and we adore being first. We are naturally early adopters seeking techniques that we might claim we discovered and/or promoted before anyone else.
This post is not about the next big thing. This post is not about the dramatic. This post will not have a number needed to treat of less than 100. No, this post is about very little indeed.
If you are interested in not a lot then read on.
If you want the next big thing then there are many sources to learn about our next direction of travel in resuscitation and many early adopters out there who are rightly leading the way. I love and respect them all.
If you are a regular visitor then you will know that we have more than a passing interest in cycling. The Sky pro team is based very close to Virchester and we occasionally see riders out about on the roads around the city. The success of the Sky team and GB cycling in general is well known and well documented. A highly professional team backed up by psychiatrists, technical wizadry, imported coaches and fabulous facilities made a real difference to athletes and ultimately led to success in the Tour de France and at the Olympics.
Clearly there were many changes that contributed to the success but today I wanted to focus on one individual, and one concept that arguably made a difference, but only a tiny one.
Matt Parker held the post of ‘Head of Marginal gains‘……..a ‘newspeak’ job title if there ever was one. What did this mean? What’s the point of a head of marginal gains and what might they achieve?
If you work in complex systems such as elite sport, motor racing or indeed medicine huge changes in performance are rare. It’s unlikely that we will find a new technique that would take a whole second off a 100m sprint time or we would find a new aero package in formula 1 that will make Red Bull go 3 seconds a lap faster than everyone else. Major change, step change, dramatic improvements are rare. In complex systems marginal changes are more important but there effect is almost imperceptible and therefore they can often be perceived as not being worth the effort, but is that right?
In my youth there was a car that I coveted more than any other, I travelled to Le Mans to see them race (and win) and was fortunate enough to get up close and personal one with one some years ago. The car was the McLaren F1 road car, an amazing machine that provided a step change in performance. It was truly an incredible machine.
Why was this? Did it have a thermonuclear powered engine? Did it bend the laws of physics? Did it do one single thing that dramatically changed car technology? Arguably not. What Gordan Murray did in designing the car was to look for any and all tiny marginal gains. I remember an interview with him at the time where he was asked about why he asked for the tools in the on-car toolkit to be made from titanium, clearly the marginal gains from lighter weight were marginal in a car that weighs 1100Kg. Those few extra grams saved would have made no measurable difference to outcome, no difference to performance and no clear link between the increased cost and outcome. What was the point of such attention to detail? Similarly in cycling Matt Parker (and the secret squirrel club) looked for small aspects in all domains of training, behaviour and equipment that had the potential to make a difference. In isolation the changes were unlikely to produce a change in performance, but they were identified, adopted, delivered and most importantly accumulated. There’s a nice review of his work here.
So why should we pursue marginal gains?
Simply put they are additive. Marginal gains don’t in themselves make a difference, but by summating together final performance improves.
So what about healthcare?
Let’s think about the resuscitation room and something that yo udo on a regular basis. Think of trauma resuscitation, sepsis or cardiac arrest. Do you resus processes go as well as they can? Do you achieve rapid transfer of patients from ambulance to trolley, do you always have the equipment you need to hand, how good are you at chest compresssions, ensuring time off the chest is minimal, that depth and rate is perfect all the time, every time?
I suspect that if you reflect back on your performance and your team’s performance you would have to be honest in saying no. There are many small aspects of process that don’t work perfectly, but perhaps they are not worth expending energy on them as they would not make that much of a difference….. I’ll give you an example. Our resus trolleys have kit in closed drawers rather than in open visible trays as I have seen in other departments. This is not a major problem. I can get in the drawers and it takes maybe an additional few seconds in our current system. What’s the point in changing? It’s a marginal gain. It would not make a difference.
The thing is though, there are potentially hundreds of marginal gains in my department. None of which will make a big difference, all will require work, it will be difficult to motivate myself and colleagues to deliver them. It will be hard.
Matt Parker and Gordon Murray are examples of leaders whose success has been contributed to by paying attention to the minor elements of their practice. Gordon is now designing incredible machines for the future and Matt has gone to English Rugby (so expect success for both). You can read more about Matt on this very nice blog post here.
You may be familiar with the phrase ‘don’t sweat the small stuff’. I ask you to consider the wisdom of this common phrase in healthcare. Sure, you want to look for the next big thing in resuscitation, but before you go for the next super therapy just make sure that you have the small stuff sorted.
Here at SMACCGold we listened to Karim Brohi talk on major trauma management. One of the strong messages he gave is that we need to do everything as well as well as we can. In his words we must first sweep the floor.
— Karim Brohi (@karimbrohi) March 19, 2014
So, get marginal, start perspiring and join in me in asking for us all to agree that….
‘It’s time to sweat the small stuff’.