The Men and Women in the Arena: Sydney HEMS and the Culture of Prehospital Resuscitation Excellence

Awesome afternoon working with @SydneyHEMS pic.twitter.com/6TuXevXY88

— Michael Lauria (@ResusPadawan) July 30, 2015

The Men and Women in the Arena: Sydney HEMS and the Culture of Prehospital Resuscitation Excellence

By Mike Lauria

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

-Theodore Roosevelt

On April 23, 1910 President Theodore Roosevelt stood before an audience of more than 2,000 people at the Sorbonne in the Grand Amphitheater at the University of Paris. In his speech, titled Citizen in a Republic,Roosevelt railed against cynicism, against those who criticize openly and often, and against those that readily throw stones from the safety of the shadows.

Roosevelt passionately espoused that the success of a people did not rest on their brilliance or intellect, but rather was built squarely on the foundation of their character and work ethic. As he emphasized in his famous quote, the essence of learning, developing, and improving is primarily contained in simply doing, in trying hard regardless of outcome. In fact, it is quite clear he believed it was much better to strive and to stumble, than to never have tried at all.

In the context of prehospital and retrieval medicine, I consider these words to be the bedrock upon which excellent teams and great organizations are made. Yet the substance that organizations use to build their daily practice is sometimes much weaker. It is, I believe, easy to cite the evidence and proclaim the bland theory of ivory tower medicine in a conference room, on a stage, or at the break room table. It is another thing entirely to translate that knowledge at the bedside or in the back of an helicopter with a critically ill, deteriorating patient when time is short.
In July and August of 2015 I traveled to Sydney, Australia and spent more than a month working and training with the physicians and paramedics at Sydney HEMS. In short, it was an amazing experience. I learned so much in the skies over Australia and at the training grounds of the Bankstown Airport . It’s always great to pick up different clinical tips and tricks when visiting another service, but here I discovered much more. While working with the men and women at Sydney HEMS, I was reminded how you build a culture of excellence, a culture where providers are not afraid to step into the arena.
One of the first things that quickly became apparent to me was the fact that many of the physicians had made substantial sacrifices to work as retrievalists. Many were senior trainees that had gained tremendous experience and seniority at other institutions. Some were even consultant (attending) physicians that had given up their jobs elsewhere to come and work for trainee pay.

You might argue that it’s simply the allure of flying around in a helicopter and winching onto beaches that draws these individuals. I would counter, however, that this is only a small contributing factor. The chief driving force is, I believe, the stuff of great organizations: a group of people willing to step outside of their comfort zone and take on a new, unfamiliar challenge.

Awesome evening hanging out in Sydney w/ @cliffreid @HawkmoonHEMS @namasteCCRN looking forward to fun few weeks pic.twitter.com/nVo9tDkJp5

— Michael Lauria (@ResusPadawan) July 19, 2015

This desire to stretch one’s capabilities and test one’s skills is symptomatic of something called a “growth mindset.” This concept was first proposed by prominent Stanford University psychologist Carol Dweck. Her decades of research have linked this characteristic to success in myriad occupations and identified it in countless preeminent organizations. In a growth mindset, people believe that their most basic abilities can be developed through dedication and hard work. Their intellect and preexisting skills are simply starting materials. Furthermore, they view difficulty as a challenge and failure as an opportunity to improve.

Openness and willingness to challenge oneself were recurrent themes during the weeks I attended the Sydney HEMS induction training. The training is primarily performance based, filled primarily with scenarios. Many of these are, to say the least, difficult. The scenarios not only present clinical challenges, but also human factors problems; they are filled with obstructive providers, intoxicated bystanders, and distractions of every variety. It’s not easy to stand up and be evaluated in any circumstance, scenarios like this most of all. Furthermore, it is always much easier to evaluate than to be evaluated. I find that, often, individuals that enjoy moderate to substantial experience begin to shy away from the very public forum of training performance and sit comfortably behind a clipboard.

Another fantastic thing I saw at Induction, was experienced physicians and paramedics would subject themselves to the training again. They may have had years of on the job, and even previously been evaluators themselves, but that didn’t matter. At Sydney HEMS, being “experienced” was not something you could hide behind. Everyone had to perform. Throughout the training we (myself included) made mistakes and failed. I was impressed at how well everyone acknowledged their mistakes, took criticism in stride, laughed at the comical blunders, and moved on. No one was persecuted and everyone came out of each scenario having learned one more important lessons. This attitude and mindset wasn’t limited to the induction training.

As with any air medical service, the call volume ebbs and flows. There are busy days and there are slow days. My contention is that another thing which separates great retrieval organizations from all the rest is what the team does on the slow days. How an organization acts when they are not on a mission, directly impacts performance. Therefore, I was really impressed to see a consistent, voluntary participation in focused practice. It wasn’t formal, structured, or organized. I would just walk out into the hangar and see the paramedics building different rescue systems, challenging one another, trying different techniques, and honing their skills. Again, this is the stuff of great organizations. Of course, a culture like this and a training program like Induction are not possible without the unflagging effort of teachers, trainers, and mentors. At Sydney HEMS it seemed that they constantly worked just as hard, if not harder than the trainees.

For example, I noticed that during the Induction weeks the physicians and paramedics running the events were at the base before the everyone else arrived and stayed late after the students left. They worked tirelessly throughout the day setting up stations, moving equipment, organizing groups, distributing paperwork, and ensuring that things moved smoothly: all this in addition to instructing. Perhaps what was most inspiring was even after long days of training, they stayed even later to discuss how they could continue to improve things.

My understanding from talking to the physicians and paramedics who had been at the program for many years was that developing the current culture had taken some time. Rome wasn’t built in a day and, as it turns out, neither was Sydney HEMS. It was the result of dedication, hard work, and grit. It was the result of many debates, much politicking, and innumerable forays into the difficulties of influencing human behavior. It was, in short, the consequence of be willing to step into the arena day after day. Yet, in the end, it was worth it. The end result is a truly superior organization. The culture and mindset at Sydney HEMS ranks among that of most elite coalition special operations organizations around the globe. I am a better retrieval practitioner for having worked and trained with them.

The citizens of New South Wales are safer and better off with such a phenomenal team providing their retrieval service. Their days in the arena have produced clinical and operational dividends. These things they do…that others may live.

Thanks to the amazing crews at Sydney HEMS, including the pilots, air crewmen, and mechanics. A very special thanks to my friends, teachers, and mentors: Cliff Reid, Karel Harbig, Brian Burns, Geoff Healy, Fergal McCourt, Clare Richmond, Toby Fogg, Yash Wimalasena, Ruby Hsu, Sarah Coombs, Marty, Hutch, Paul, Rob, Cam, and Sam. Take care and stay safe.

.@GeiselMed @DartmouthHitch honored to be speaking to the physicians & paramedics @SydneyHEMS clinical governance day pic.twitter.com/y5ZELCV1qw

— Michael Lauria (@ResusPadawan) July 29, 2015