SCCM Resource Library-Frontline Nursing: Leadership Lessons From the Battlefield to the COVID-19 Crisis

Video Transcription

Ladies and gentlemen, please welcome the 2022 SCCM Congress Co-Chairs, Dr. Jose Diaz, Dr. Megan Lane-Fall, and Ms. Heather Meissen.  Good morning and welcome to the start of the second week of the 2021 SCCM Virtual Congress.  I am Jose Diaz, and along with Megan Lane-Fall and Heather Meissen, as Co-Chairs of the 2022 SCCM Congress, we invite you to join us in San Juan, Puerto Rico, February 4-9, 2022.  The SCCM is planning to return to our standard format for the 2022 Annual Congress, live and in-person.  What better place to hold the 2022 meeting than a tropical paradise of San Juan, where we'll showcase all that's new in critical care medicine. That's right, Jose.  Year after year, the SCCM's Congress Program Committee develops solid education that appeals to all areas of critical care medicine.  While we've had to pivot to a virtual meeting this year, the committee has already begun planning for a live meeting next year.  The Planning Committee, and even you, the SCCM members, developed some excellent session proposals for presentation in San Juan that you won't want to miss.  I'm sure many of you remember the last time that Congress was held in San Juan, Puerto Rico.  And like me, Jose, and Megan, you are looking forward to returning, especially if our lives have returned to some form of normalcy following this tragic pandemic.  Sunny San Juan offers a peaceful tranquility in February, and with a wide variety of hotels and meeting space available to us, it will easily accommodate the 2022 Congress.  I hope to see each and every one of you next year in San Juan, Puerto Rico for Congress 2022. Ladies and gentlemen, please welcome Dr. Anne Tescher. Good morning.  It is my distinct pleasure to introduce this morning's plenary speaker, Dr. Elizabeth Bridges, who will be presenting the Norma J. Schumacher Honorary Lecture.  Dr. Bridges is Professor of Biobehavioral Nursing and Health Informatics at the University  of Washington School of Nursing in Seattle, and Clinical Nurse Researcher at the University  of Washington Medical Center, where she partners with extraordinary nurses to conduct research and bring evidence to the point of care.  She is the current President of the American Association of Critical Care Nurses, and is  a well-known presenter for her applied critical care research and the translation of evidence into practice.  In October of 2014, Dr. Bridges retired with the rank of Colonel after 30 years of service in the United States Air Force Nurse Corps.  She is the editor of the Tri-Service Nursing Research Program Battlefield and Disaster Nursing Pocket Guide, which is the primary resource for all military nurses preparing  to deploy, and is also a contributing author to the SCCM's Fundamentals of Critical Care Support, Austere and Operational Environments.  Her many honors include the AACN Distinguished Research Lecturer, the AACN Flame of Excellence Award, and the Military Legion of Merit Medal.  Today, Dr. Bridges will present Frontline Nursing, Leadership Lessons from the Battlefield  to the COVID Crisis, and will be available for a live question and answer session immediately following this presentation.  Ladies and gentlemen, please help me in welcoming Dr. Elizabeth Bridges. Good afternoon. My name is Dr. Liz Bridges, and it is my pleasure to be here today.  I'd like to thank the Society of Critical Care Medicine for the honor to present the Norma J. Shoemaker Plenary Lecture.  As a background for today, let me give you a little insight into a military deployment. These are pictures from Bagram Airfield in Afghanistan.  As I wrote in a column for the American Association of Critical Care Nurses, I deployed in a war zone always knowing that I was not completely safe.  I lived in a bubble for six months. My life rotated around going to work, the gym, and the chow hall, and an occasional  trip to the market or some other activity just to give you a little bit of respite. But you couldn't go anywhere without your weapon, your personal protection.  I saw the same people every day, and contact with my family was by email and an occasional 30-minute phone call, during which I never spoke about what was really going on because  it was hard to explain, and I really didn't want to worry them. Does this sound familiar? Because I think right now we're all living a very similar experience.  And while there are risks in using the metaphors of the military to describe our current situation,  there are leadership lessons from the military that directly translate to our current experience. And today I'd like to explore a few of those with you.  The vision of the military leadership often comes through the media. Some characters are heroic. They leave us inspired by their bravery.  But the movies are also full of characters who bark orders with the expectation that they're immediately followed, no matter the consequence.  And these characters may make for good TV or a movie, but they're not military leaders. I've learned in my military career that the most powerful leaders are those who don't  have to put their rank on to lead. These are the individuals who are authentic and inspire each other.  As General Dwight Eisenhower said, you don't lead by hitting people over the head. That's assault, not leadership.  From the day you start your military career, you're taught to be a leader. You're expected to be a leader.  Today authentic leadership is taught in every leadership course, and one of the basic tenets of authentic leadership is vulnerability, an attribute that is certainly the antithesis  of the characters we see in the movies. It's about saying, I don't know, and then partnering with others to listen and to answer the question.  Authentic leadership involves acknowledging uncertainty, but also leading with courage and confidence.  Kevin Cashman, who's an executive coach, says, effective leaders speak to influence and motivate. Exceptional leaders listen to learn, collaborate, and innovate.  Leadership isn't about barking orders. It's about listening and growing others. Early in my career, I learned more about leadership from my department chair in critical care.  Her background was in OB. She didn't know a lot about the specialty of critical care, but what she knew and who she was was a leader.  And the leadership lesson she taught me over 30 years ago has stayed with me. She'd say to me, Lieutenant, what do you think we need to do? And then she'd listen and support.  Recently, I've had the privilege of supporting the vaccine clinic, and on the first full day in the clinic, many of the volunteers were medical and nursing students.  And as we moved through the day and sought to refine our processes, that question came back to me. My question to them was, what else do you think we need to do?  And my job as a leader was to listen. At squadron officer school, I and 800 of my classmates had the privilege of hearing Admiral Grace Hopper speak.  She was a computer scientist who was recalled to active duty at the age of 60. Admiral Hopper led the team that created COBOL and the first commercial electronic computer.  She was also famous for coining the phrase, the bug in the system, after a moth obstructed a relay and completely crashed their computer system.  She was an innovator who abhorred the phrase, it's always been done that way. And in this time of turbulence, our leadership lesson is that we can continue to do business  as usual, or we can hear the words of Admiral Hopper as she advises us to set sail and to do new things.  In the military, in addition to education about our professional role, we complete formal year-long courses to help us become better officers.  During one of these courses, the leadership lesson came from the classic movie, 12 O'clock High.  The character played by Gregory Peck, General Savage, was brought into a bomber squadron with a high rate of losses, in part compromised by the unit leadership.  The plan was that he would only stay until a replacement commander could be found. He adopted a command persona to instill confidence in the men.  He communicated that he would be hard, but he was also willing to sacrifice himself for them. And at some point in time, he's offered the opportunity to leave, but he says no.  He's become adamant that this is his mission, and only he alone can accomplish it. He drives forward alone.  At the end of the film, he goes out to get into the plane to fly another mission, and his legs refuse to move. He has a complete breakdown.  He sits staring into space until all the planes have come home, and then he goes to sleep. For me, there are a lot of lessons in this film, but the lesson that I take forward as  we continue to respond to this pandemic is that the heavy burden of leadership cannot be carried alone. You need to find your wingman.  The movie also teaches us a more current military axiom, as stated by Lieutenant General retired Mark Hertling, who said, the fatigue makes cowards of us all.  Military leadership guides state that sleep should be considered as critical as any logistical supply, like water, food, fuel, or ammunition.  Sleep leadership, which is the proactive allocation of adequate sleep, is important not only for  subordinates, but for leadership, and in a military's leadership guide, there's a priority given to sleep allocation for leaders who are making decisions critical to mission success  and unit survival. Sometimes adequate sleep enhances both the speed and accuracy of decision making. I don't know about you, but that sounds like critical care leadership to me.  We need to explore this unique aspect of our leadership. Ask yourself, when was the last time you truly had a day off when you were completely unplugged?  Early in the war, our team of military scientists received a call with a simple message. There will be no hypothermia in theater. Fix it.  This was followed by a series of frantic calls with the parameters. The solution had to weigh less than seven pounds, be small enough to carry in a backpack,  and use minimal or no electricity. Other than that, we could come up with whatever we wanted.  My colleagues, Dr. Joe Smeltz, Dr. Don Johnson, Dr. Marla DeYoung, Karen Evers, and myself,  all nurses, undertook a series of studies to identify the solutions that met these requirements. The solution that became the hypothermia prevention kit is still in use today.  As a scientist, I've done my job. I responded to the message to develop a technical solution.  But as leaders in science and healthcare, it's not sufficient to simply create a technical solution.  It takes a system-level translation to ensure the uptake, dissemination, and sustainment of an innovation.  So the hypothermia prevention kit in this technical solution was embedded in the first joint theater trauma system clinical practice guidelines on hypothermia prevention, which  through leadership support and standardized implementation strategies across the entire  war zone, resulted in the reduction of accidental hypothermia to less than 3% for all U.S. and coalition casualties, even during the coldest months of the year.  These results are comparable or better than anything we see in civilian trauma systems.  But if you stop and you think about what we've accomplished, and I'm proud to have played a small part in it, this is a technical and a system-level solution to a problem.  But is that enough? As I consider our military lessons learned, I wonder, as leaders, are we asking the right questions?  In a study of battlefield fatalities, 87% occurred in the pre-hospital setting, with 24% considered potentially survivable. That's almost 1,000 lives.  The most common injury was extremity hemorrhage. The U.S. military initiated an aggressive program to bring tourniquets to the point of injury.  Each of us carried two tourniquets and learned how to apply it not only to ourselves, but to others.  The effective use of tourniquets has essentially eliminated extremity hemorrhage as a major cause of death on the battlefield.  It's estimated now that for every 100 potentially survivable deaths, 8 are from respiratory compromise and 92 are from bleeding, mostly from the torso.  So at recent military conferences, the discussion has shifted to explore how to decrease mortality in these casualties,  including the beneficial effects of the rapid administration of blood within 15 minutes of injury, including low-titer whole blood and plasma.  But as evidenced in these photos, we've been trying this for a long time.  For example, when we initially deployed to war, the tourniquet we had was relatively unchanged from the Civil War and World War II,  although now through systematic research, we have something that is far more effective. At one of these military conferences, I had the privilege of talking to Dr. Paul Carlton.  Dr. Carlton was the former Surgeon General of the Air Force, and he's an innovator. And he asked a very simple question. He said, where are our soldiers getting injured?  Many of the injuries occur during convoys involving the transport of fuel and water.  And he surmised that maybe the solution isn't the treatment after the injury, but solving the logistic problem, creating new strategies to supply fuel and water.  This is not something that normally a medical officer would consider. But his powerful leadership lesson is that we need to think upstream.  And he says in his book, Upstream, we need to solve problems before they happen.  Consider all of the challenges that we have faced over the past year for which we've applied a technical solution. I wonder if we're asking the right question.  This is a board in our emergency room in Bagram for trauma patients arriving within an hour.  IED or an improvised explosive device, the patient is intubated with bilateral globe injuries,  bilateral lower extremity fractures that have already been stabilized with external fixators and a fasciotomy. The second casualty has multiple facial fractures and is intubated.  The third with a BKA. To clarify, someone has added the word sick in case we weren't sure. The fourth casualty was not sick.  He was stable with a below-the-knee amputation and lower extremity fractures.  I'd ask you, in what world is someone who has just suffered traumatic amputation not considered to be sick? Here's our ICU board.  Gunshot wounds, fragmentation wounds, head injury, BKA. Eleven patients, eight on vents, three beds open. And we're also serving as the recovery room.  Over 60% of our patients evacuated from theater had polytrauma. So as I look at the characteristics of these patients, what's the leadership question here?  I think it's how do we create a seamless system of care that's 8,000 miles long,  where the outcomes are as good as stateside trauma systems, particularly in those with the most severe injuries.  In the book Better, Dr. Atul Gawande asked the same question.  He wrote an essay called The Casualties of War, where he explored this question and asked why there had been such a historic reduction in the lethality of battle wounds.  He explored three aspects, technology, system, and a constant vigilance over details. And what he suggested is that while technology and the system are important,  the success was about making the science of performance. To investigate and improve the knowledge and technologies we already had, rather than waiting for new discoveries.  It's the constant vigilance over the details of performance that is the basis of the question that I like to ask. How do you know you're making a difference?  The success of the military system to improve outcomes for our wounded warriors and the potential to translate these lessons to civilian health care  were explored in a National Academy of Medicine report with the emphasis on creating a learning health care system.  The central tenant of this system are continuous supply of data and information and leadership.  The report praised the military's approach to implementing new products into the guidelines through a process called focused empiricism.  Based on our need to use the best data and expertise to answer urgent questions and to constantly ask, how are we doing? What can we do better? Are we making a difference?  Now at various stages of this crisis, I think it's been hard to find time for even a moment's respite. Let alone consideration of data collection.  But the lessons of the military demonstrate that it can be done. And I think the importance of the early reports  and the powerful webinars we had from our colleagues in China and Italy as we began to understand the severity of the pandemic, the social challenges, and the complexity of care.  And while it's not possible to study every question, what are those that need immediate answers that can be best answered now so that we can iteratively improve care?  The decision to move forward with focused empiricism requires bold leadership to acknowledge uncertainty, to pause and ask, what are we doing? And are we making a difference?  And to recognize that the time committed to performance improvement is productive time driven towards a goal of optimal patient outcomes.  But I think there is something at the core that is even more important than what is summarized in the NAM report.  My job during the deployment was as the Director of the Deployed Combat Casualty Research Team in Afghanistan. Much of the research that we facilitated focused on the epoch of care.  But as an Air Force officer, I was always interested in the care that happened between the hospitals during the transport phase.  And more importantly, research that captured the entire continuum of care as the casualty moved, who was injured in Afghanistan, began their 8,000-mile journey transport home.  The importance of the continuum of care and the core value that is required was captured beautifully in a short piece written by my colleague  and friend Dr. Zolt Stockinger, a Navy surgeon. And in this piece he tells the story of a wounded Marine who received CPR and survived.  During the surgery at the field hospital, his critical injuries were stabilized and a team of nurse anesthetists administered over 45 units of blood and blood products.  But this wounded Marine's journey home had just begun. He was transported and being stabilized to the next level of care  where they learned he received another 100 units of blood and blood products. And then on to the next stop and the next stop. Hopefully home, hopefully to his family.  As Zolt says, he and his family do not know our names, nor do they need to. We are just a few of the hundreds of people who make up the many links  in the several thousand-mile long chain of medical care for our wounded Marines, sailors, soldiers, and airmen. If one link breaks, it all fails.  As leaders, it is our responsibility to look across the system and also to convey to every person at every point the importance of being all in.  During this pandemic, we've seen the power of this lesson as our patients move from the community and assisted living  through our medical system on to the next stop and the next stop. Hopefully home, home to their families.  We cannot think in isolation or stovepipes as we respond to this ongoing crisis. When I ask people what's the thing you want to take forward out of the experience,  the first answer is always partnerships. Partnerships with each other, partnerships with care providers across the medical team,  and most importantly, partnerships across the continuum of care where we all come together in purpose-driven action.  The lesson from the military that I learned in the war zone is the lesson we need today, and it's the need to be all in.  I'm an avid reader, and I have a bookshelf full of books about military nurses and health care and leadership. One of the sets of books are the stories of the Angels of Bataan,  the 77 nurses who were captured when Corregidor fell during the war. In 1942, these nurses were taken prisoner, and almost three years later in 1945, all 77 of them came home,  despite hundreds around them dying of starvation and disease. And while each of these women went on to face a lifetime of challenge, why had they survived?  They said it was their work that would save them, their sense of themselves as professionals and the knowledge that they were part of something larger and more enduring  than any one of them alone, and that something was the group. Our circumstances are nowhere near as dire as the experience of these nurses,  but our professionalism and the power of connection to each other is just as important today. In his book, Make Your Bed, Admiral McRaven, the former commander of special forces,  talks about ten lessons to change the world. One of the lessons he learned during SEAL training is captured in the idea,  if you want to change the world, find someone to help you paddle. As Admiral McRaven explained, to avoid flipping over in the surf,  every person in the boat needs to pull together with equal effort and at the direction of the coxswain who steers the course.  He talks about how this lesson comes alive in the realization that we need to reach out to those around us to help us through difficult times.  I see those same lessons of the boat when I look around me. I see the importance of the leadership lesson that none of us can stand alone.  We need to ensure that each person is a leader in their particular role, and now, even in the midst of this crisis, we need to continue to develop leaders  so that everyone can step in and be the coxswain. These are two of my favorite statues, the Vietnam Women's Memorial and the Combat Medic Memorial.  They honor the profession that I'm proud to be a part of, and although it hasn't always been so, today the military is honored.  As a veteran, I can only say it was my privilege to serve. Recently, health care providers and essential workers have been lauded as heroes.  People bang pots and pans, murals have been painted, and a whole lot of food has been delivered to the hospital. Being a hero buoys us up.  I know from talking to all care providers that there's a palpable sense of pride in saying, I'm a doctor, I'm a nurse, I'm a respiratory therapist.  But our job titles and being called a hero may also come with a burden. There is an expectation that heroes don't cry, that we can walk unscathed through this treacherous landscape.  Some of our colleagues feel frustration or guilt over their perceived inability to contribute more. We should not willingly accept the title of hero if the expectation is that  our responsibility is to face danger without question.  We have a right to expect that our moral obligation to care is met by the moral obligation of our organizations and society to care for us.  Do I think that health care providers are heroes just like the military? Oh, yeah, every day. This is who we are and what we do, but not without restriction.  Our duty of leadership is to communicate how to consider challenge of our ethical duty to care and our ethical duty to self.  In the tactical combat casualty care course, the first lesson is care under fire. And in this lesson there are a series of five very graphic photos from a real  world event that capture the fatal wounding of a soldier and the subsequent wounding of two medics who rushed to help.  The point of the slides is to reinforce the need to move a casualty to a position of safety before attempting any medical care,  and also the importance of the medic in the overall response. Medics are not disposable. As health care providers, our natural inclination is to run in,  to do what we're trained to do. But just as discussed with being called a hero, the ethics of care is not unidirectional as evidenced by this organizational mandate in the TCCC.  This is the leadership embedded in the clear guidance that while we have a duty to care, we also have a duty to self.  We see this in the dilemma that this bidirectional duty creates when we've had to develop the protocols for cardiac arrest.  Just as in the military where there are unequivocal guidance, there must be an organizational mandate and clear leadership that honors both the duty to care and the duty to self.  The final lesson comes from a military leader who underwent unspeakable threats. Admiral James Stockdale was a prisoner of war for eight years.  And as recounted in the book Good to Great by Jim Collins, Admiral Stockdale was asked about how he dealt with the horrors of his situation when he couldn't know the outcome.  His answer, which is now known as the Stockdale Paradox, was based in an ancient stoic philosophy. And he said, I never lost faith in the end of the story.  I never doubted not only that I would get out, but also that I would prevail in the end and turn the experience into the  defining event of my life, which in retrospect, I wouldn't trade. Admiral Stockdale went on to say that the most important lesson was that you  must never confuse faith that you will prevail in the end, which you can never afford to lose, with a discipline to confront the most brutal facts of our current reality,  whatever they might be. He instilled this same belief in his fellow prisoners. And for this act of leadership, he received our nation's highest military award, the Medal of Honor.  As I move through this pandemic, this is the leadership lesson that carries me forward. To have my feet firmly planted in reality, we can't ignore it,  but also turn towards a hopeful future, one that we can create together. Thank you for the honor to present today.

Video Summary

Dr. Elizabeth Bridges, a well-known critical care nurse and researcher, delivered a plenary lecture at the Society of Critical Care Medicine (SCCM) Virtual Congress. She began by sharing her experiences as a military nurse in Afghanistan, highlighting the importance of leadership and teamwork in high-pressure situations. Dr. Bridges emphasized the need for authentic leadership, which involves vulnerability, listening, and collaboration. She also discussed the concept of "making your bed," which symbolizes taking responsibility and working together to achieve shared goals. Drawing from her military background, Dr. Bridges identified several leadership lessons that can be applied to the COVID-19 crisis. She stressed the importance of a seamless system of care, partnerships among healthcare providers, and forward-thinking approaches to problem-solving. Additionally, she highlighted the significance of continuous data collection and analysis to drive performance improvement. Dr. Bridges concluded her lecture by urging healthcare providers to acknowledge the challenges they face and to maintain faith in a positive outcome while confronting the reality of the current situation.

Asset Subtitle

Crisis Management, Administration, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Differentiate leadership requirements on the battlefield and during the COVID-19 crisis
Discuss leadership during crisis: lessons learned and evidence regarding leadership in an operational environment and implications for current leadership
Discuss leadership after a crisis: evidence-based leadership to support reintegration and growth

Norma J. Shoemaker Honorary Lecture

Elizabeth J. Bridges

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Area Administration

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Nursing

Tag COVID-19

Year 2021

Keywords

Dr. Elizabeth Bridges

critical care nurse

authentic leadership

military nurse

COVID-19 crisis

seamless system of care

continuous data collection

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