The Point of Calling It Out

I thoroughly enjoy mental models, if you have not figured it out. I feel like they have greatly improved my pre-hospital care practice and developed my character. I have recently been working on process improvement at work, which lead to this blog. 

It is so easy to fall into complacency in our work environments. For as much as pre-hospital providers like to say that they enjoy their jobs, because they go to work every day not knowing what will happen – I want to challenge that. More often than not, the parameters most of us work in during our shifts at work… are normal. There are significant lulls and even running calls. I bet most of us can make a list of things we do and calls we run during the shift that are normal, expected, and outright mundane in our line of work. It is easy to fall into a routine, miss things, look them over, or even get so complacent that deviance may get normalized where you work and are not challenged. 

If you’re not using a mental mode, you generally could be coming from one of two areas:

  1. You just go with the flow; what happens, happens, and you hopefully figure it out as it happens with little preparation and panic as possible. 
  2. You use your instincts and prior experiences to make decisions but still do not have formulated courses of action for specific events you are experiencing. 

Mental models are cognitive representations of how we view our external environment. Having at least a casual understanding of how problems you face interact with each other can allow a person to draw upon domains of knowledge they already have and better understand systematic connections when facing a problem (Jones, et al 2011). Mental models can be a driving force in the growth and mastery of many skills we do in pre-hospital care; from patient care to scene management and personal growth. 

One of the places I have fallen short as a leader is often asking my crew to be better at having situational awareness. It’s easy to see this as an everyday thing to ask of a crew, partner, or anyone working in public safety and pre-hospital environments. The leadership at my agency was seeking ways to better get compliance, buy-in, and overall culture change from good to great in how our team checks out vehicles during the day. This jogged my memory about a practice I had often done when we unload a patient from the back of the truck: If I’m at the head of the bed, I’ll look down and point to areas of hazards, vent tubing, infusion tubing, O2 tubing, cables and so forth. I’ll also verbally say, “both sides look clear.” or something to that effect. 

What was jogged in my memory was watching a video about Japanese train conductors and platform workers. When noting hazards, these individuals would point to them and call them out. Check it out:

It’s 3 minutes and 16 seconds. Go watch it. I’ll wait until you come back…

Shisa Kanko

Enter shisa kanko, roughly translated as “pointing and calling.” It’s cited as coming from the Japanese mass transit industry. It is credited to Yasoichi Hori, who was a train conductor who was suffering from failing eyesight. The story goes that due to his poor vision, he would point out signals, and his firemen would confirm them. This was around the early 1900’s, and sometime around 1913, it made it into the railway operation manuals as “kanko oto” or “call and response.” It then evolved from there and has even been noted to be used to a lesser extent by the New York MTA (Moon, 2017). I genuinely believe there are a lot of applications for this in pre-hospital care. They range from individual tasks to tasks undertaken by your team and even interacting with other teams. Think of shisa kanko as a verbal and action-driven checklist that helps unite cognitive thought with physical action. It also may help ingrain mindfulness in our actions as we go through checklists and other high-stake operations.

Albeit it’s an older study, in 1994, the Railway Technical Research Institute of Japan studied this concept. It was found that while doing simple tasks, workers made 2.38 mistakes for every 100 actions. With the application of shisa kanko, there was a rather significant reduction in these errors to .38 errors per 100 actions, which makes for an 85% reduction in errors (Powell, 2017). 

Furthermore, this practice helps distance you from working on autopilot and helps you actively think about what you’re doing. You combine visual, auditory, and kinesthetic inputs and outputs to help reduce error. There have even been noted an increase in blood flow to the brain during the use of shisha kanko, with no increased strain on perceived workload by end users (Kay, 2020). Obviously, this was an experiment. It was not in pre-hospital care, and it’s obvious someone needs to run this study for their grad school project, which is in pre-hospital care. 

That being said, I think there’s something to take home from this. At the personal level:

  • Think about getting ready and leaving for work during the day instead of just saying you’ve got your keys and overnight bag and your packed lunch. What if you actively point to it and verbally say it?
  • If you’re working as a solo provider, it provides you with a higher level of focus. Think about doing it after you’ve drawn up meds, packaged a patient, or when organizing your thoughts for a high-stakes IFT. “I’ve got extra pain, and sedation meds were drawn. They are taped to my leg (point). I’ve checked the chart for my medication rights and will do so again when I reconfirm the dose before giving them (point to chart, med guide, or vials).”

As a team, I think this shines as next-level closed-loop communication:

  • You’re packaging your patient and getting ready to move to your ambulance or aircraft. “Hey, when we get to the aircraft, we’re going to keep exposing our patient from the waist down (point). I’ll look for IV’s here and here (point), you set up these meds, and we’ll go for pressors in the right arm.”
  • You’re giving a report on your patient to the receiving team. “This is Mr. Smith. He was involved in a head-on conclusion, from head to toe, he has X, Y, and Z injuries (point). He is intubated, and the vent settings are XYZ (point to tube, vent, etc.). He has bilateral AC access (point).”

I think you get the point (and calling) here. You’re combining all the ways you can communicate and think about something as you set about to do it. 

We’re starting at work using this for truck checks. Why? Because mornings are busy, people are human, and we’re not perfect. We realize that. How often do you check out your vehicle for the day and something gets missed? In my entire career, this is by no means a rare event. It can be pretty frustrating. This allows for a discussion. As our team goes down the list of ’10 essentials,’ it builds in time to have a discussion with the off-going shift. It adds accountability, as well as builds in direct communication so things can be recognized and fixed. “The fuel is good (point). Hey, its below half. You guys seemed busy. I’m glad we caught it. We’ll take care of it, but next time I’m eating your lunch when you do it.'”

Jones, N. A., H. Ross, T. Lynam, P. Perez, and A. Leitch. 2011. Mental models: An interdisciplinary synthesis of theory and methods. Ecology and Society.

Kay, S. (2020). Shisa Kanko could reduce mistakes and save lives. Cambridge Medtech Solutions.

Moon, J. (2017). Conduct Yourself. Topic.

Powell, S. (2017). The Japanese skill copied by the world. 1994 study by Japan’s,– a massive 85%25 drop.

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