It’s a Tuesday in mid December 2011 and we are heading out of Sydney Heads to prepare for the Sydney to Hobart Yacht Race. We were all preparing the spinnaker and getting ready for a practice gybe set. It was 18 knots and the sea state was quite mild. It was just a typical, normal day at “the office” for now.
A huge cloud formed above us, just like you see in the movies and we knew what was coming, the wind swung around 90 degrees. We had far too much sail up and unfortunately on this particular day we had no reefing lines in the main sail. Waves literally came out of no where and as the vessel dove under a wave, a life raft exploded off the deck. Before we knew it, it was in the water and fully inflated. We did a quick crew check and soon realised we had a Man Overboard!
We could see the crew member in our wake, he was at least 100 meters away. Then the storm hit. The horizontal rain made it impossible to locate the casualty. We went into our well practiced MOB sequence, however this time it was a real person in the water, it was not a fender.
Dan Buoys were released, Life rings were thrown. The sails were dropped and we made a swift figure eight, I felt my heart rate increase and that feeling of dread sweep over me. I started to repeat my Emergency Response mantra, DRABC (Danger, Response, Airway, Breathing, Circulation) in my mind & jumped down below to retrieve Oxygen, a Trauma Kit, Blanket and the Defibrillator.
Our swimmer quickly donned his wetsuit and flippers. We located the crew member, and could see he was upright in the water. Other crew members went about unrolling the Jacobs Ladder, which we had never used. It was taking too long so we deployed a helicopter sling on a halyard.
The Captain manoeuvred the vessel and we gracefully stopped one meter from the patient. The swimmer attached the helicopter swing and we retrieved the crew member, and next the swimmer.
I looked at the patient, he did not look good.
I knew that ghostly shade of white and that clammy skin. A guest started to panic
“He´s dying, do something, do something” they screamed.
The First Mate calmly turned to the guest and said “We are well trained in this kind of emergency, we are going to get him out, but we need to do it in an orderly way. Would you kindly go below and get us some paper, a pen, a blanket and some sugar”
The guest scurried off and looked relieved he could be of assistance.
DRABC, DRABC, DRABC my brain recited. As most of you know I am an Emergency Nurse and have specialised in Hostile Environments and Remote Medicine. I train yacht crew in these kind of scenarios and I am also a professional Sailor. Fortunately, I had been training the crew in First Response Medicine and we had done numerous drills onboard this yacht only 3 weeks before.
The thing is, you can do all these scenarios until you are blue in the face and it does not always prepare you for the real thing. In the Trauma ward I have my uniform on, a stethoscope around my neck and I am ready for chaos.
On this day, I was there to sail. I did not have my “Trauma hat on”. I was thinking about sail trim, our next manoeuvre and what type of sandwich I would eat today! I was not expecting this and I knew I had to switch hats, so to speak. It was time to step up as a leader.
We lay the patient on the foredeck and the Captain turned down wind. We felt this was the safest place to assess the patient, as sailing downwind was relatively flat and the vessel was well controlled. Crew members were delegated to various roles, one took the airway and provided spinal support. Another did a body sweep and we noticed the Crew members femur (upper leg bone) was broken, it appeared to be a complicated fracture. Another member took his vital signs, while another contacted our Medical Provider. I put a cannula in his vein, we administered pain relief and the Kendrick splint to his broken leg.
The crew member was warmed and treated for hypothermia while reassurance and emotional support was provided. Suddenly the whole situations appeared seamless and it actually felt so controlled, it felt like it was just a drill.
So, what made this horrific accident turn a chaotic environment into a relatively calm one and how did we turn our own anxiety into aligned, life saving, action so fast?
I am glad you asked because in this article I will outline my top 5 tips to be able to step into leadership, in any extreme emergency, which will give you the ability to control an adverse situation at any at any moment and put your emotions and fear at bay.
While these steps may appear obvious to the reader, they are often overlooked in times of panic and when we are faced with the unexpected or a situation we cannot control.
When a tragedy happens, we feel scared and fear can be debilitating. Fear generally comes from fear of the unknown. A strong leader is able to inspire their team to perform well under any circumstances, despite the emotions they may well be experiencing at the time.
- Step Up
When we have to step into leadership in an extreme environment we must be pragmatic. I like to “calm the farm” which means get it together, mentally, physically and emotionally, fast
I use the DRABC method, the same one we teach in Elementary First Aid. I apply this mantra to all emergency situations, I will explain my rationale now.
I check for danger. The biggest danger right now, is my own clarity and focus as a leader. First of all we must make sure we are in the right headspace to make good decisions and lead confidently. I close my eyes for one moment and take a breath. I consciously decide at this very moment that going forward I must respond not react. I remind myself I know what I am doing & that I am a leader. I then recite the Medical DRABC, Danger, Airway, Breathing, Circulation.
I stand up tall and open my own airway, giving me more confidence. I then take note of my breath rate, I have done numerous emergency retrievals and literally holding my breath. This not good for clarity, as our brain requires a constant flow of oxygen to think clearly. Many of us only take shallow breaths in an emergency and this, I believe, only adds to our anxiety.
I then use C for Circulation as a que to feel my heart beat and I consciously regulate it, by focusing on the awareness of just the feeling of my feet on the ground, I try not to think, for a moment to clear my mind of any unwanted thoughts. This only takes a split second, I believe self awareness and feeling grounded is crucial step to maintain effective leadership.
- The Brief
Once you have calmed the farm it is important to tell each crew member what is expected of them and what role they will take. Even if you have practiced a scenario a million times, people are reassured with guidance and knowing what is expected of them.
Remember all kinds of suprises are unleashed in an extreme event. Personalities can and will change. You will generally end up with a mixed bag of strengths and weaknesses that you must direct. The common personalities that will surface are the team builder, team player, innovator, nurturer, jokester. Not to mention the negative roles of the attention seeker, over achiever, critic, negativist and of course the snowman (the one who just freezes!).
It is your job to build the team, remind people of your common goal, specific roles and functions that must be performed. Your Crew members and Guests need to be treated with respect and yelling is not going to help at this time. The more clearly you delegate roles appropriately, the more influence you will have as a leader.
Remember to avoid being the jack of all trades. You will have way more control watching this, with out your hands full. For many of us in charge it is often all too easy to try and do everything ourselves, this is dangerous and how things get missed.
One word, Delegate!
Research has shown leadership starts with your belief in your own ability to help. Humans have an instinctual urge to fight a threat or try to flee from it, it is known as the fight or flight response. A major factor that contributes to which instinct will win out is how competent you believes yourselves, and your team, to be to respond to the situation.
It is important for someone to assume what we call the ‘Medical Officer’ role. This person directs the actions of others, outlining very specific goals to be accomplished.
Crew members should be situated according to their strengths, mentally, physically and emotionally. Please remember that at this point that the partner or close friend of the patient, or the untrained, may or may not be able to perform. There is a good chance they will be in shock and require treatment as well.
Ask another crew member to call 112 (or the emergency number in your current country or for your 24/7 Medical Response provider) and be your point of contact. Have someone else direct the human traffic. If someone does not like blood, get them to collect the Medical kit, water, blankets or anything that will make them feel useful. Keep a careful eye out for other crew members who are not coping and re-define their role.
In the scenario I described above, remember how we got the guests involved to the best of their abilities. Engage them. Enlist their help. People deal better with an emergency if they feel useful, keep them busy and feeling part of it, even if they are not required at or on the scene.
- Conflict Management
In any extreme situation there will always be some conflict. In yachting the questions that arise are often as such…
- Do we turn around or keep going
- Do we call a helicopter or coast guard
- Do we send the patient to an unknown hospital, alone
- Do we give “Dangerous” but lifesaving drugs, like Morphine, Tramadol or Diazepam?
- Do we move the patient or leave them where they landed?
It is important to acknowledge peoples opinions, preferably not in front of the patient. Make the chain of command clear and take a moment to listen to any reasonable opinions of all involved. Most of all be confident in making the safest possible decision for the patient, the vessel and the crew at all times.
Clear communication protects the safety and performance of all involved. Clear commands and keeping your orders short and simple is vital. Ensure all team members are aware of each step you plan to take and the rationale for the protocols which you intend to use. Communication and respect for the crew members roles is vital at this time. It is also important to make each team member feel valued and that their opinion matters.
I would also like to point out that it is also important to remember that a patient will become compartmentalised, so the team members applying bandages to the leg, may not know what is happening up at the patients head, just like sailing a boat!
Always provide the patient with a support person, who offers reassurance and it is critical to ask the patient for consent. It is also most important to communicate each step to the patient and empower them to feel safe and in control.
There is nothing more frightening than having people all around you doing things to your body and you have no idea what they are doing, or why. Especially when needles, oxygen masks and medicines are involved!
- The Debrief
I have been involved in a number of Medical Emergencies at Sea and the critical point of difference in the psychological effects on all involved is the debrief.
A mid way debrief is also most beneficial during each step of the recovery, it is ok to stop for a few seconds and review what you have done, getting feedback and data from all crew members involved. This is an area that is often missed. For example, we stop just for a moment and talk through the patient care from head to toe. This way we can be sure nothing has been missed.
After the patient is stabilised or taken to safety, it is important to initiate a final debrief with all guests and crew. Allow everyone to discuss their experience. How it felt and always offer follow up counselling and support to all involved. The biggest advancement I experienced in the Trauma Ward was when we implemented post incident support teams, who would take all first responders and literally treats us for shock. They would give us a blanket, a sweat cup of tea, put our feet up and provide the reassurance that we did all we could. I highly recommend this becomes a standard part of any major incident.
I have also been involved in accidents where the boat kept sailing and not a word was every spoken amongst the team. This leaves the crew and guests feeling confused, uncertain and generally causes a higher percentage of Post Traumatic Stress complications. I cannot emphasise the power of a debrief enough.
Since most of us only partake in medical training one day a year, if that, I recommend using visualisation and regular scenario trainings to project what you would do in an emergency scenario. Practice this regularly and discuss it with your crew. Think a couple moves ahead. If you’re not anticipating you’re not in a position to be proactive.
I would like you to consider, how does this apply to you? Do a quick risk assessment of your current protocols & knowledge base. What are the riskiest places and actions you undertake every day? Where are you most likely to encounter an emergency? Most importantly, how do you think you would lead your team and perform?
Then consider how you can apply the DRABC and Step Up, how you would implement the Briefing, Conflict Management, Effective Communication and the Debrief into your next Leadership role. Most of all, don’t forget to breathe!
Please note, this story has been compiled of a number of incidents rolled into one for educational purposes and most of all to provide Yacht and Patient confidentiality for all involved.
Amanda Jean Hewson Beaver RN (BSCH, MIPH)