Publications

Scholarly Journals--Published

• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Improvisation in High-Reliability Organizing (HRO): 1. Red Noise Engagement. Neonatology Today 18(7): 60-76, 2023. Invited Red noise produces functions forcing a response from a population. Pink noise creates abrupt catastrophic change that may require resetting or changing learned behaviors at-the-moment, if not starting over. For some reason, the organized approaches for these situations derive from stable white noise environments. These environments differ significantly in stability versus change, thought, information, precision versus accuracy, error versus correction, decision-making, and problem-solving. Red noise environments limit our ability to design for forcing or abrupt events effectively. These events cannot be deflected, contained, or suppressed. Entering the environment by way of improvisation is a practical approach to engagement. Operational organizations have decades of history of engaging in dangerous contexts. (07/2023)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Impaired Engagement in High-Reliability Organizing (HRO): 4. Situational Cognitive Distortions. Neonatology Today 18(6): 34-54, 2023. Invited Rather than describing the environment as a structural entity, the HRO views the environment as the flow of environmental energy. Energy has frequencies, and we can use sound and light to model characteristic energy flow patterns. White light contains all wavelengths of visible light. Long wavelength light (low frequency or long period) is red. Red light has a low frequency but carries more energy. We may better understand individual or organizational responses to risk or hazards if we consider them a response to a specific type, or ‘color,’ of environmental noise. Our initial response to an adverse or hostile environmental, red noise, is affective – give value to environmental signals and ensure self-protection. How we manage that affective response can augment our cognitive capacity or distort our cognition. It is known that High-Reliability Organizing increases stress capacity and reliability of the organization. What is under-recognized is how this happens: utilization of human affective responses to increase cognitive and stress capacities of individuals, teams, and groups. (06/2023)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Letter to the Editor: “Response to HRO: Engagement Matters” How to Employ Full Spectrum Analysis to Improve the Quality of the Response. Neonatology Today 18(5): 54-55, 2023. Invited Your presentation of mystery-solving versus problem-solving and searching the full spectrum of domains enabled our public safety and healthcare group to become more effective while operating in crises. Your paper gave substance to our experience and improved our capabilities. The benefit of mystery solving not only advanced effectiveness but also became our means of introducing novices to decision-making in ambiguous situations. When pediatric critical care was starting, there were no books. Full Spectrum Analysis and mystery solving explained our work in the PICU and helped expand the same approach into pediatric chronic care. We now infuse FSA into our HRO articles for Neonatology Today. (05/2023)
• van Stralen, Daved, Sean D. McKay, Errol van Stralen, Thomas A. Mercer. Impaired Engagement in High-Reliability Organizing (HRO): 3. Reasoning Impairs Engagement. Neonatology Today 18(5): 63-76, 2023. Invited We engage contingencies to make them more orderly. Removing context supports objective approaches that are also more orderly. 'Subjective' becomes a derisive term. Preparation for abrupt change includes well-developed plans and people who follow those plans. The event itself is not a part of the planning. This resulting normative stance is transportable and favored by leaders and scholars. An organization or industry institutionalizes competency because generalizable principles can be taught to a high-turnover, novice workforce. Abrupt change makes visible the fundamental gap between reason and action. Cause-and-effect relationships are less visible because nonlinearity allows multiple causes to generate multiple effects. The color of environmental noise, the flow of events, and one's position inside or outside the event benefit from different levels of analysis. Arguing across these different levels creates false debate. The dominant account, relying on classical logic and deductive reasoning, becomes a mistranslation of the environment. Modal logics support inference in situations of incomplete information and can drive action. Paraconsistent logics support contradictions and treat inconsistencies as informative. Paracomplete logics allow continuous change; there is no need to assume "A" or "not-A." The ability to work under uncertainty must not be sacrificed for the tractability of objectivity. (05/2023)
• van Stralen, Daved, Sean D. McKay, Errol van Stralen, Thomas A. Mercer. Impaired Engagement in High-Reliability Organizing (HRO): 2. Information Impairs Engagement. Neonatology Today 18(4): 37-51, 2023. Invited Information has specific qualities that adapt it for engagement. Correlation as a descriptive term strengthens engagement, while causation as an explanatory term can mislead engagement. Information flows and has a contextual range of values and can combine with local experience. Information is stored as revisable (belief) versus not revisable (knowledge). Information reduces uncertainty, except in the flux of rapidly changing events. Disturbances and disruptions make the gap between stable and unstable situations and between theory and practice visible. Theories, classifications, and the standards necessary for high- risk operations can become idealized, impairing information and engagement. The belief that more data illuminates the problem and directs us toward the solution will occupy valuable assets. Data collection in these ‘reddened’ environments increases information variance, disintegrating reliability during the flux of events. (04/2023)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. High-Reliability Organizing (HRO): Engagement Matters, Is Personal, and Initiates Enactment 1. The Color of Noise Impairs Cognition. Neonatology Today 18(3): 20-36, 2023. Invited The characteristics of abrupt crises are the elements that cause stress and fear. Stress impairs cognition, fear generates defensive behaviors, and existential threat drives aggressive behaviors. Nobody wants this; organizations expend effort to prevent or mitigate stress and fear. Unfortunately, these efforts promulgate and normalize belief in the inevitability of stress. Fear becomes normalized through situationally accepted behaviors such as anger and intimidation, creating the ecology of fear. These same stress responses, fear reactions, and amygdala reflexes drive engagement in the situation. Engagement mitigates and resolves the crisis. Engagement also modulates the stress responses, fear reactions, and amygdala reflexes that enable that engagement. Counterintuitively, stress-impaired cognition, fear-circuit behaviors, and amygdala-driven reflexive behaviors caused by the crisis are necessary for engagement in that crisis. (03/2023)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer Engagement in High Reliability Organizing (HRO): The Individual Matters. Neonatology Today 18(2): 30-45, 2023. Invited Understanding and engagement have a strange relation with a situation. We fit the situation into our understanding, then use the situation to extend our understanding. We do this through engagement. Engagement is what bridges the gaps between objective knowledge and subjective experience. The situations we engage are moving toward disorder. Engagement creates structure as it generates information. But this is information in flux, meaning that engagement constantly updates our information as we continually revise our understanding. Information changes in salience, meaning, and relevance. Effective engagement relies on attitudes, values, and reciprocal decision making. Up close, and engaged, the fog of war is the starting point for the creation of structure. (02/2023) (link)
• van Stralen, Daved, Sean D. McKay, Errol van Stralen, Thomas A. Mercer. High Reliability Organizing (HRO): Engagement Matters, Is Personal, and Initiates Enactment. Neonatology Today 18(1): 25-37, 2023. Invited Organizations don’t engage, people engage. There are circumstances we encounter when we cannot choose to not act. Unfavorable risk-benefit ratios are not a reason to decline. Lack of engagement becomes Karl Weick’s ‘enacted failure by not acting.’ Engagement is contextual acting within an unstable environment, and that acting removes constraints on acting. Context is the effect of subtle, nuanced, ephemeral details. Engagement makes use of and strengthens the individual’s sense of self-efficacy and internalizes their locus of control. Separated from contextuality are those in positions of leadership. “To engage” becomes the initiator for action. Action becomes the source of learning. Learning and action generate experience. (01/2023) (link)
• van Stralen, Daved, Sean D. McKay, Errol van Stralen, Thomas A. Mercer. Disaster Series: The Function of Engagement for High Reliability Organizing (HRO). Neonatology Today 17(12): 16-28, 2022. Invited Random, stochastic variation creates fluctuations in the environment. The organization must respond as these fluctuations become forcing functions or create an abrupt catastrophe. This variation is described by the color of noise – reddened noise frequencies or pink noise. Operations during these events uncover gaps between theory and practice, which are bridged through engagement. Engagement is behavior that has defensive functions against threats to the organization, supports thinking through motor cognition, initiates self-organization for directed responses, generates information during the flux of events, and creates a structure within a volatile environment. We describe the function of engagement in High-Reliability Organizations (HRO) as a process to use the situation to extend our understanding. (12/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: The Failure of Lessons Learned (LL) and the High-Reliability Organization (HRO): Experience-Conceptualization-Contextualization. Neonatology Today 17(11): 20-34, 2022. Invited Lessons Learned programs are continually at risk for "conceptual arrest" – the Lesson Learned that is a concept, an abstraction, something that has not, and cannot, be contextualized. A disaster creates abrupt gaps between what we thought we could do, what we must do, and the urgent necessity to engage the situation. Lessons Learned convert these experiences into more effective organizational performance and improved capabilities of personnel. In these volatile and uncertain environments, a failure is an option. The belief that a dangerous context can be engaged with the same organizational and cognitive approaches as a stable environment leads to ineffective, even dangerous, Lessons Learned. Effective Lessons Learned come from an integrated program of full-spectrum analysis, appreciation of the crisis environment, and knowledge of stress and fear modulation. This is not a mixing of academic concepts with field experience. It is an integration of how concepts are used in crises – we have experience-conceptualization-contextualization. (11/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. High-Reliability Organizing (HRO) for Disasters: Capability and Engagement. Neonatology Today 17(10): 18-32, 2022. Invited  We reviewed first-person accounts of NICU staff who experienced disasters and were published in the medical literature. A disaster comes from stochastic environmental noise acting as 'forcing functions,' the strength of the environment to force a system or population to respond. The sensory effects in a disaster are overpowering – sounds, temperature, smells – and can degrade performance. A disaster brings together diverse infrastructures of organizations and disciplines accustomed to collaborating. A disaster is an environmental disruption of medical care, a victim generator that disrupts the ability to treat multiple patients. Our goal becomes survivability, preventing deaths that result from post-disaster events. Of over 400 affected neonates, only two deaths occurred during these disasters, and no deaths occurred during evacuations. These disasters revealed the effective actions and contextual leadership of the typical Neonatal caregiver, clearly demonstrating HRO as natural human actions when freed from convention and central authority. (10/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Consequences – Initiating the Path to High Reliability Organizing (HRO). Neonatology Today 17(9): 24-35, 2022. Invited High Reliability Organizations emerged as an effective response to consequences. Designing a response from the antecedent events, causation, or the situation misses vital subtle and nuanced information. Immediate consequences from apparently mundane circumstances, forcing functions, or abrupt catastrophic events share the same possibility of outcomes – dramatic failure. They also share the same approach of engagement. Appreciating the effect of consequences guides every member of an organization toward vigilance for early heralds of faikure and engagement that creates enactment. (09/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Identifying Gaps – Entering the Path to High Reliability Organizing (HRO). Neonatology Today 17(8):29-42, 2022. Invited The human brain evolved to act against consequences, yet models of decision making rely on information processing. Crises occur in volatile environments, yet organizations rely on plans and planning. The gap between fluctuating events and static concepts and models creates inconsistencies that are solved under pressure at the local level. We identify the more consequential gaps, describing their origins and structure. Some gaps are readily bridged but some gaps present existential danger, such as the gap between identity or beliefs and the environment. (08/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. High Reliability Organizing (HRO) is Contextual. Neonatology Today 17(7):36-50, 2022. Invited   HRO emerged from engagement with a flux of contingencies in an effort to make them more orderly. We cannot treat these environments as isolated systems with demarcated boundaries. Rather, the environment is comprised of open, contextual systems always in flux. Contextual systems are those systems where the environment interact with and change the problem. These sequential events are better viewed as ‘state vectors’ acting like arrows in time, rather than discrete, sequential events. Rational (‘top down’) and heuristic (‘bottom up’) cognitive approaches have limits when engaging these dynamic open systems. We propose that context-focused engagement reduces the error of “engaged abstraction” and that quantum cognition contains elements used by HRO operators. (07/2022) (link)
• van Stralen, Daved, Sean D. McKay, Christopher A. Hart, Thomas A. Mercer. Implementation of High-Reliability Organizing (HRO): The Inherent Vice Characteristics of Stress, Fear, and Threat. Neonatology Today 17(6):26-38, 2022. Invited High-Reliability Organizations engage threats and adversity to maintain reliable operations. Human stress, fear, and threat responses drive safe and effective engagement of environmental threats. The executive functions integrate perception from opposite ends of the brain, hastily created plans, and motor activity. During a crisis, the hypothalamic-pituitary-adrenal (HPA) axis enables survival behaviors by releasing cortisol to “disarm” the executive functions. Novelty, uncertainty, and uncontrollability, in the domain of the executive functions, cause stress responses. Fear reactions at the subcortical level maintain a safe distance from the threat. Threat reflexes rapidly initiate protective behaviors. However, these same responses, when unmodulated, can harm the individual. The prevalence of unmodulated stress, fear, and threat makes them appear unpreventable, if not normal. This is the inherent vice of stress, fear, and threat. By describing their function and location in the brain, we can identify these behaviors to begin modulation for effective responses to threats. (06/2022) (link)
• van Stralen, Daved, Sean D. McKay, Christopher A. Hart, Thomas A. Mercer. Implementation of High Reliability Organizing (HRO): The Inherent Vice of Stress, Fear, and Threat. Neonatology Today 17(5):24-35, 2022. Invited The human mind evolved to naturally engage adversity – whether in the environment or from an enemy. Behaviors and our environment will be unpredictable because they are continuously oscillating, creating frequencies, and some of those frequencies have long periods. It is the long period frequency, acting alone or with other long period frequencies, that create forcing functions. Individuals, organizations, and the environment must respond in some manner to these forcing functions. The human brain will release corticotropin releasing factor (CRF) which goes to the hypothalamic-pituitary-adrenal axis (HPA) and the HPA terminates ongoing activity, suppresses the executive functions, and impairs abstract cognition. Concurrently, CRF enters the locus coeruleus-norepinephrine system (LC-NE) to reorient cognition for attention and arousal – adaptive cognition is started, the individual focuses on behaviors, and engagement follows. (05/2022) (link)
• van Stralen, Daved, Sean D. McKay, Christopher A. Hart, Thomas A. Mercer. High Reliability Organizing (HRO) for the Color of Noise: Forcing Functions, Collaboration, and Safety. Neonatology Today 17(4):19-39, 2022. Invited The aviation industry operates in an environment where forcing functions and catastrophes can be deadly to the public and not easily explained away. The industry formed a safety improvement collaboration known as CAST, the Commercial Aviation Safety Team. Within ten years, the fatal accident rate decreased from the pre-CAST rate by more than 80% while also improving productivity. Signals carry information while noise interferes with information. This distinction is one of predictability versus unpredictability. Noise as stochastic variation may represent unrecognized influences in the system. To exist in a world of stochastic variation, biological systems must maintain a dynamic stability that is far from equilibrium. The meaning of the types of environmental stochastic noise comes from the characteristics of their fluctuations that cause unpredictable events and the energy of their ‘forcing functions.’ Frequencies with the power to force a system or population to respond to the environment are forcing functions. White noise environments follow the Gaussian distribution and are amenable to prediction, algorithms, rules, and protocols. Red and pink noise develop from autocorrelation, the feedback from the past influencing the present or a system interacting with other systems. Red noise environments with low frequency forcing events have greater influence on the system than white noise. Red noise environments contain ill-structured problems requiring use of heuristics and experience. Considered as a response to reddened frequencies, we can discuss safety as information about long period events and forcing functions or as the forcing function itself. The threat of punishment and litigation incentivized pilots, as it currently does healthcare professionals, to hide their errors and near misses and to not report the errors and near misses of others. (04/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Operational Logics and Inference During [1/f or f -1] Noise Events: High-Reliability Operations (HRO). Neonatology Today 17(3):18-31, 2022. Invited To prepare for and operate in stochastic environments we study, and even master, academic models. The environmental stochastic noise separates the world of practice from scientific theory. Oscillating and fluctuating processes create frequencies of power, the color of noise, and unpredictability. These environments also contain the determinants of stress, putting individuals at risk of the peculiar Logic of Stress and the ecology of fear. It is by logic, a logic of practice shared by those who crossed the threshold with us, that we effectively engage these environments. Not classical logic, though. Modal logics conform to changing events and support flexible thinking. Paraconsistent logics support inferences from contradictions. In a topology, the central concept is continuity and how the elements preserve a notion of nearness by a continuous function. They maintain connectedness during deformation without tearing apart to create a new boundary (03/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: High-Reliability Organizing (HRO) as Self-Organization. Neonatology Today 17(2):14-27, 2022. Invited Oscillatory processes, basic to the functions of life, are intrinsic to the stability of physiological systems. After oscillations gain stochastic resonance the power spectrum increases in lower frequencies – as environmental stochastic noise, uncommon events gain greater influence on the system. Even weak or relatively small stochastic noise can create and sustain significant oscillations. In physiology, stochastic noise disruption beyond normal bounds is associated with disease, creating the phenomena we observe and treat. Pink noise, the 1/f oscillation, has an increasing power spectrum at low frequencies producing abrupt, rapid fluctuations that bring catastrophic failure. Self-organization promotes stability and stable patterns. As a response to stochastic noise, self-organization is an agile, adaptive response that starts with engagement of the situation. Paraconsistent and modal logics work with inconsistent and contradictory information and the different ways things are true. Motor cognition adjusts our actions to changing situations, we learn through physical actions. Mirror neurons help us understand the intent and actions of others during self-organization, creating a gateway to social cognition. During a disaster, operations occur in a topological space which constrains and facilitates actions in pink noise crises. Self-organization is the natural and effective response to disruptive environmental stochastic noise. (02/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: Appendix 1: Hurricane Meteorology. Neonatology Today 17(1):30-32, 2022. Invited The Hurricane Environment. For those who do not live where hurricanes are common, we offer a short glossary of terms to better appreciate the events and threats during a hurricane. (01/2022) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: Prolonged Improvisation during Hurricanes – High Reliability Organizing in the NICU. Neonatology Today 17(1):10-27, 2022. Invited NICU preparation for a hurricane includes evacuating or sheltering neonates, agreements to transfer neonates, communication, and emergency transport systems to move neonates to safer ground. Under-represented are identifying the skills and capabilities to support a neonate for hours, if not days, in an austere and adverse environment. The successful operations that sheltered and evacuated 235 neonates with only two deaths and no adverse events recorded are under-recognized. Such accomplishments came about from the actions and improvisations of local Neonatologists and NICU staff who extended an ordinary workday into the consequences of major hurricanes.  (01/2022)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: High Reliability Organizing for (HRO) Disasters – Disaster Ecology and the Color of Noise. Neonatology Today 16(12):96-109, 2021. Invited The frequencies of stochastic noise inherent to the environment can be described as colors. The various colors of noise refer to the disruptive potential of stochastic energy within the environment and its characteristics. The meaning of the type of noise lies in the unpredictability of events and the ‘forcing functions’ of energy. That is the strength of the environment to force a system or population to respond. For human activity, the color types correlate to problem characteristics such as leadership-line authority coupling, well-structured, ill-structured, and embedded problems. When the noise color changes, forcing functions and the types of problems also change, increasing characteristics necessary for adaptation or altering characteristics in unexpected ways through relaxed selection. The noise process applies equally to nursing homes, NICUs, and public safety and is independent of timescale or magnitude. We need not characterize normal environmental variation differently from catastrophes.  (12/2021) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: The Abrupt NICU Evacuation – Disasters without a Plan. Neonatology Today 16(12):10-22, 2021. Invited An abrupt disaster brings the environment physically into the NICU. We describe immediate evacuation measures taken because of a ruptured water pipe, hospital fire, unexploded WWII bomb, and two earthquakes. These abrupt changes thrust the Neonatologist into an environment with new structures, rules, and threats. The intruding environment dictates actions at first as the Neonatologist addresses safety for the neonates and staff while continuing medical care for the infants. The environment has just become the pathology, a new comorbidity. Operations during abrupt change mean the Neonatologist must hand off direct minute-to-minute care for the neonates, trust staff, then begin the more demanding work of figuring out next and future steps. Personal stress and fear responses must be modulated while supporting staff during the uncertainty. While these events at first appear disparate, they share the common problem of rapid movement of neonates to safety, ensuring the safety of infants and staff while solving problems embedded in a threatening environment. Faced with an abrupt environmental threat, we must maintain awareness that disaster and medical professionals will not appreciate the unique responses of the neonate to the raw environment. We must accept and rely on our colleagues’ strength, fortitude, and creativity in the NICU to resolve problems embedded in the environment.  (12/2021) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer.  Disaster Series: The Use of Information for Wildland Fire and the NICU: Combined Evacuation and Sheltering. Neonatology Today 16(11):105-114, 2021. Invited Wildland fire threatens the hospital, evacuation routes, and even the use of vehicles. Smoke-filled air endangers the neonate inside the NICU or ambulance while poor visibility can ground helicopters. The wildland fire environment is under continuous change from fire behavior determined by topography, fuel characteristics, and wind. This creates a fire environment of poor air quality and road closures or congestion. The decision to evacuate or shelter changes, sometimes by the hour. Therefore, NICUs planned simultaneously to evacuate and shelter. This review revealed two different systems for decisions and coordination of evacuation depending on governmental support. Regardless, NICU staff were the ones making specific decisions and preparations for evacuation or sheltering. (11/2021) (link)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: Understanding Disasters – Classifications and infrastructure. Neonatology Today 16(11):9-18, 2021. Invited A disaster is an environmental disruption of medical care, a victim generator that disrupts the ability to treat multiple patients. We classify to understand and make sense of the world, but a disaster has flux, uncertainty, and ambiguity, bedeviling our ability to classify. Structures in the abstract are more amenable to classification and give a sense of order. This ‘top-down’ perspective, however, is outside the flux of events. Within the flux of events, a ‘bottom-up’ perspective, the operator is personally at risk and changing contexts necessitates updating less reliable information. In classifying, we lose details due to irrelevance, but what is irrelevant now may become relevant later. Different communities working in the disaster space may or may not cooperate. ‘Boundary objects’ are ambiguous, yet constant objects shared by adjacent domains, contributing to cooperation even when the communities don’t understand each other. Infrastructure as human behavior reaches beyond the single event. We can identify and use boundary objects for rapid development of communication when disaster brings diverse organizations together. (11/2021)
• van Stralen, Daved, Sean D. McKay, Thomas A. Mercer. Disaster Series: Elements of a Disaster. Neonatology Today 16(10):108-115, 2021. Invited A disaster is an environmental disruption of medical care, a victim generator that disrupts the ability to treat multiple patients. Death can come from physiological, physical, social, or behavioral threats within the disaster environment. Legal or administrative definitions of disasters are necessary for out-of-area resource allocation. Topological dynamical systems describe the continuous transformations within the topological space of a disaster. A functional description of disasters focuses on the damage produced by the disaster rather than how the damage was caused. An ecological description underscores how damage creates a new environment within our familiar, formerly safe work environment. The disaster environment can have a latent effect on physiology in several ways. The disaster forms an embedded problem, an ill-structured problem embedded in the environment. We extend operations into disasters by developing capabilities rather than assessing risk. (10/2021) (link)
• van Stralen, Daved, Elba Fayard, Julia Paz, Louisa Shelby, Mitchell Goldstein, T. Allen Merritt. Disaster Series: Disaster Planning for Perinatal/Neonatal Medicine: Rethinking the Process and Caring for Mothers. Infants and Technology Dependent Infants - The Time is NOW. Neonatology Today 16(10):9-22, 2021. Invited Disasters that affect health care delivery seem to be happening with increased frequency and can be found all around us. Within the last month, the Caldor Fire in Northeast California resulted in the evacuation of Barton Memorial Hospital in South Lake Tahoe. Hurricane Ida caused the loss of electrical power and loss of water to New Orleans Children’s Hospital, making an evacuation of their NICU and other patients to other hospitals necessary, according to the Chief Medical Officer, Dr. Mark Kline on CBS Good Morning America (August 30/2021). We aim to review how disasters, both natural and manmade, threaten the well-being, indeed the very lives of pregnant women, newborns, and especially the lives of technology-dependent infants and children. We offer novel approaches for critical decisions and actions that accomplish our life-saving goals. (10/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. Inductive Processes, Heuristics, and Biases Modulated by High Reliability Organizing (HRO) for COVID-19 and Disasters. Neonatology Today 16(9):104-112, 2021. Invited We view and understand the world through our internal logics, both public and private internal logics. The logic of practice differs by frame of reference – a fixed point or within the flux of events, which can have “cosmology episodes” that collapse sensemaking. We have different perceptions and capabilities from the different reference frames, Eulerian and Lagrangian specificities, and Euclidean space and topological space. When approaching a situation, all we have is observation, induction, and the capability to learn through action. Because people have limited time and knowledge, they must make inferences from the information they have available. For complex, interactive problems and processes, we almost universally use heuristic, subjective approaches for better decision-making. Heuristics work through the nearness of information between the old problem-solution and the new problem, a topological space. In routine operations we are susceptible to heuristic bias, yet, counterintuitively, error corrects this heuristic bias. We have found four predominate heuristics that cause consequential bias and interfere with effective decision-making: availability, representativeness, confirmation bias, and over conservative revision. Motivated reasoning, a fifth bias but not from a heuristic, overly scrutinizes information that conflicts with closely held beliefs. Unless we assume that every word and behavior could instantly be wrong, we can too easily begin treating our treatments.  (09/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. High-Reliability Organizing (HRO), Decision Making, the OODA Loop, and COVID-19. Neonatology Today 16(8):86-96, 2021. Invited Organizations do not make decisions; people do. The entropy of any system moves toward disorder of its elements and the corruption of information as it is transmitted. This flux creates uncertainty. As we gain additional information, we find that the property of monotonicity from classical logic and scientific reasoning does not allow us to change our conclusions. We must engage with these situations without a developed plan or even without a plan. Reciprocal decision-making describes how we act, observe the response to our action, and how that response guides our next action. Decision-making with reciprocal feedback keeps the operator close to events, generates information, identifies relevance, and gives meaning to information. This is an active method for generating information, creating structure, and identifying the boundaries of performance. John Boyd’s OODA loop is a cycle for rapid, real-time interactive hypothesis development and testing. This is not decision-making independent of others or the organization. The Orient function of Boyd’s OODA loop integrates the individual, situation, and organization through culture. (08/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. Common Sense High Reliability Organizing (HRO) in the Response to COVID-19.  Neonatology Today 16(7):90-102, 2021. Invited We find descriptions of common sense in the domains of anthropology, artificial intelligence, and psychiatry. This is the common sense for adaptation, a form of practical intelligence that better predicts success in everyday experiences, if not real-world survival. This common sense is experienced-based knowledge rather than rule-based. When unexpected situations occur, it supports continuous assessments and decisions to adjust to the conditions at hand. Overwhelmingly practical, common-sense deals with a concrete situation on its own terms. Common sense describes cultural knowledge and behaviors. Inquiry drives practical common sense. (07/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. High-Reliability Organizing (HRO) and Abrupt Change from COVID 19: Failure of Scientific Rationality and Classical Logic. Neonatology Today 16(6):97-109, 2021. Invited Neonatologists built the science of neonatology with logic and rationality. The cognitive processes of scientific rationality and classical logic, developed for a structured environment, are poorly defined for operational use. The first impairments from even mild uncontrollable stress are in the cognitive and memory areas of the brain. A ‘cosmology’ event collapses our sensemaking even as we believe in our own rationality. The novice does not have personal anecdotes that are protective in such a collapse. When applying the abstractions of logic to a particular concrete situation, we can fulfill our own sensemaking, or we can make sense for the good of the community. It is the premise and logic that differ. The dominant narrative from scientific rationality and classical logic has become privileged with the loss of knowledge gained during risky operations. Such lost knowledge creates inaccurate models with long-lasting effects on education and policy. In the operational environment, lost knowledge can kill. (06/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. High Reliability Organizing (HRO) is the Extension of Neonatology during Pandemic COVID-19 Neonatology Today 16(5):97-109, 2021. Invited Neonatology began with the extension of care to smaller babies born earlier in gestation and now extending into the threat of COVID-1. Extending operations into a new environment places everyone in novel situations. Emerging from actual operations within dangerous contexts, HRO extends operations and the organization into uncertain, adverse, and hostile environments. The physical actions of care come from motor cognition, the influence of the cerebellum and motor cortex on cognition, and how we learn through physical action to understand events. Rather than study the myriad ways a system can fail or how it can reach the final common pathway of failing, we can study and respond to it as a liminal zone. It is common to all failures – an exigency of ambiguous information, impending proximal threat, uncertainty, and demand for action. Engagement in the liminal zone is the same as engagement for extension, drawing from four domains: categorization, methods of decision making, the significance of the affective processes, and modulation of stress and fear responses. Perhaps the purpose of safety, reliability, and resilience is not to safely work in a dangerous context but to support the extension of the organization into uncertainty, a new environment, unpredictable circumstances, or to penetrate threats. When a person believes in themselves, they will leave their place of safety and engage the unknown when they know they are supported. This is the extension of neonatology. (05/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. High-Reliability Organizing (HRO) in the COVID-19 Liminal Zone: Characteristics of Workers and Local Leaders. Neonatology Today 16(4):90-101, 2021. Invited HRO has become better studied, producing concepts that bring clarity to its structure and function. Reliability, safety, and resilience, as concepts, do not carry the same immediacy of a fellow worker in danger or bringing a novice into the workforce in a way that that novice may save you. Reviewing how workers did their jobs while ensuring their own safety reveals elements of HRO that are at risk of becoming lost. We reviewed the experiences of WWII heavy bomber crews, high-rise ironworkers, underground miners, prison chaplains, fire rescue ambulance crews, and Vietnam aerial combat aviators. From their experience, we describe a VUCA-2T environment (Volatility, Uncertainty, Complexity. Ambiguity-Threat, Time Compression). Workers pass through, if not caught up in, a liminal zone. The common themes across work domains include suppressing fear, trust, helping the novice, protecting your partner, recognizing fear in fellow workers, and local leadership. Perhaps the organization's response to liminality differentiates management by high reliability organizing from conventional organization management.  (04/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. The Nature of Neonatal Experience during Pandemic COVID-19. Neonatology Today 16(3):87-97, 2021. Invited Life abruptly becomes chaotic. This is much like crossing a threshold into a room where we don’t belong. The chaotic situation entrains energy and resources, forming a trajectory to cascading failure. The HRO accepts this trajectory and members of the HRO engage in events even as they do not know how to bring it to an end. This is the liminal period, across the threshold and away from our routines. While it appears daunting, if not dangerous, this approach builds on experiences we have had throughout life. HRO methods uniquely shape the engagement that moves through and out of a liminal period. HRO is a trajectory of engagement that fuses now with the experience of then into simultaneous inquiry and redescription. In these states of engagement, the HRO supports using all our mind (03/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. The Art of Neonatology, the Art of High Reliability as a Response to COVID-19. Neonatology Today 16(2):74-83, 2021. Invited Historically, art is the skill in scholarship gained by learning or practice, evident today as a Bachelor of Arts degree or study in the liberal arts. By the 17th century, art became associated with painting and sculpture. Art, in this usage, reflects the creativity and aesthetic intention. The art of a discipline is synthesis. Synthesis extends knowledge to new heights. Alpine climbers gained height through the art of climbing. Neonatologists gain life through the Art of Neonatology. An individual can master the “science of neonatology.” Perhaps an individual can approach mastery of the “practice of neonatology.” But the Art of Neonatology, like High-Reliability Organizing, cannot be mastered. Mastery is an inductive process with continuous learning, continuous synthesis, continuous observation. Like Aristotle’s practical wisdom, mastery is an art.  (02/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. High Altitude Climbing, High Reliability, COVID-19, and the Power of Observation. Neonatology Today 16(1):68-79, 2021. Invited Attempts to climb Mount Everest failed for thirty years until a mountain climbing physiologist joined the efforts. This story demonstrates the value of context, inductive processes, and pragmatism to generate local knowledge and solutions in austere, hazardous environments. In these environments imperfect information and inaccurate models can kill. This story, viewed from the experience of the climbers rather than scientists or leaders, underscores the vitality of engaged individuals overcoming physical, social, and mental adversity to “gain altitude.” At the level of the individual, what high altitude climbers learned can support the neonatologist’s efforts for the neonate to “gain life.” (01/2021) (link)
• van Stralen, Daved, Thomas A. Mercer. Pandemic COVID-19, the High-Reliability Organization (HRO), and the Ecology of Fear. Neonatology Today 15(12):129-138, 2020. Invited COVID-19 has changed the social, financial, and political environments for healthcare. Healthcare organizations have abruptly changed operations for a new environment due to pervasive threats to the organization, patients, and healthcare professionals. While the direct, infectious presence of COVID-19 as a threat would seem to cause the greatest stress to the healthcare system, perhaps the absence of the threat may cause more severe and wide-ranging problems. Ecological studies demonstrate a greater decrease in prey populations from the absence of the predator due to an “ecology of fear.” Organizations, by analogy, share these trait responses and can develop an organizational culture of stress or for stress. HRO describes functional traits for effective operations in environments of severe threat. (12/2020) (link)
• van Stralen, Daved, Thomas A. Mercer. During Pandemic COVID-19, the High Reliability Organization (HRO) Identifies Maladaptive Stress Behaviors: The stress-fear-threat cascade. Neonatology Today 15(11): 113-124, 2020. Invited Stress has become an organizational characteristic. Organizations work toward stress reduction, seek stress management, increase cognitive capacity, attend to our mindfulness, and refer staff for anger management. The HRO acknowledges that stress, fear, and threat are natural elements of dangerous work. In fact, they are integral to, and support, actions when we don’t know how events will resolve. Rather than compartmentalize stress fear and threat, the HRO harnesses these driving forces to initiate engagement and support the resilience necessary for maintaining enactment. For this to occur, we must identify unrecognized stress for its deleterious effects on performance. As we accomplish this, the organization can harness this energy to resolve the original stimuli while achieving an acceptable, if not totally desirable, end-state. The stress-fear-threat cascade enables us to engage uncertainty and threat, but without neuromodulation, the same cascade can cause more damage than the inciting event. (11/2020) (link)
• van Stralen, Daved, Thomas A. Mercer. Pragmatic High-Reliability Organizations (HRO) Modulate the Functions of Stress and Fear Behaviors During Pandemic COVID-19: The Stress-Fear-Threat Cascade. Neonatology Today 15(10):126-134, 2020. Invited Stress and fear have biological functions that, when neuromodulated, make adaptive otherwise maladaptive responses. While the concept of a defensive cascade supports cognitive understanding and hypothesis testing, approaching this domain by function using an ecological approach brings the pragmatic stance with methods for prevention and intervention. Stress, fear, and threat have distinct functions to, respectively, constrain cognition, induce cognitive focus, and reflexively respond when in danger. We differentiate reference frames between a fixed-point reference frame that distinguishes the event (stimulus) from the person (responder and response) and an experiential reference frame within cascading events. Unrecognized, the characteristics and actions of an HRO bring modulation to the defense cascade, check the effects of stress, interrupt cascading fear reactions, and abridge threat reflexes. (10/2020) (link)
• van Stralen Daved, William Gambino. Error as a Faulty Failure Signal. Neonatology Today 15(9):114-117, 2020. Invited An organization’s High Reliability Organization (HRO) attributes can become impediments to generating reliability and safety in ill-structured, dangerous, or life-preservation contexts. To what extent do subjective perceptions of what constitutes “reliability” develop into attack vectors for self-inflicted organizational sabotage? How could internal administrative or external regulatory pressure cause an otherwise reliable organization to focus solely on the strongest failure signals, oversimplify circumstances, centralize decision making authority, vilify error, and disregard outliers? “Preoccupation with failure” becomes “preoccupation with error.” Error, then, loses its leverage for learning and understanding. The resulting fear of, or preoccupation with, error becomes an obstacle to comprehension, learning, and enactment. (09/2020) (link)
• van Stralen Daved. Management of a Symptomatic COVID-19 Positive Pregnant Woman and Her Newborn Infant [Discussion]. Neonatology Today 15(9):121, 2020. Invited A pregnant mother with a highly infectious disease delivers an infant who does not have the infection. Management of the mother and infant follow published guidelines. The mother and infant are discharged without complications (1). Free of context, the reader could view this case report as trivial. The reader would then miss the influence of pandemic COVID-19 as it brings together uncertainty, ambiguity, threat, stress, and fear, creating tumultuous medical, social, and political environments in which we operate that can, indirectly and unconsciously, drive treatment decisions. The authors of this case report did not treat, but, did they act? We must recognize the danger of not acting. Not acting is an action, possibly the most dangerous thing we do. Not acting may communicate to others disregard, dismissal, indifference, or inattention to the problem. On the other hand, not acting relies on staff with the capability to rapidly switch to mindful attention with the authority to act. (09/2020) (link)
• van Stralen Daved, Sean D. McKay, Thomas A. Mercer. Pragmatic Leadership Practices in Dangerous Contexts: High-Reliability Organizing (HRO) for Pandemic COVID-19. Neonatology Today, 15(8): 109-17, 2020. Invited The threat of COVID-19 to professionals has become personal. Professionals in neonatal healthcare can acquire infection and unknowingly become a vector, infecting babies and their colleagues. A pragmatic stance of leadership, derived from leadership in extremis, communicates to subordinates that leaders have their immediate well-being in mind while engaging demanding situations. Effective leadership for ill-structured problems embedded in the environment have distinct characteristics such as modeling cognitive and affective skills (attitudes and the contingent value of information) and the ability to modulate emotional states. Pragmatic leaders effectively increase subordinates’ collective stress capacity for, and leverage individual capabilities during, in extremis circumstances. This paper describes pragmatic leadership characteristics and practices derived from experience, primary sciences, and High Reliability Organizations (HRO).  (08/2020) (link)
• van Stralen Daved, Sean D. McKay, Thoma A. Mercer. Flight Decks and Isolettes: High-Reliability Organizing (HRO) as Pragmatic Leadership Principles during Pandemic COVID-19. Neonatology Today 15(7):113-122, 2020. Invited The COVID-19 crisis has created a physical environment where neonatologists and neonatal staff face exposure to an easily transmissible, potentially fatal infection in the course of their duties. Leaders cannot reject an assignment, such as a resuscitation of a newborn, because of risk. As in military operations, safety and capability cannot be separated from neonatal operations. Leadership models developed in stable environments do not fully translate to dynamic, uncertain situations where the leader and subordinates personally face threats, the type of environment from which the High Reliability Organization (HRO) emerged. There must be a shift from the increasingly abstract, academic, and normative representation of HRO leadership to its original, more pragmatic frame that iteratively supports engagement. The purpose of this paper is to present HRO as leadership principles, bridging the gap between abstract theory and practice by bringing attention to HRO as a scientifically supported pragmatic leadership stance.  (07/2020) (link)
• van Stralen, Daved. Pragmatic High-Reliability Organization (HRO) during Pandemic COVID-19. Neonatology Today 15(4): 3-9, 2020. Invited The COVID-19 crisis demonstrates the difficulty of translating a method of organizing developed for extreme hazards to organizations with similar demands to be failure-free but in a markedly less hazardous environment. Three central reasons for this, discussed in this paper, are 1) the incomplete translation of HRO theory into practice 2) the characterization of HRO practice: The embedded problem, and 3) the internalization of HRO practice. The purpose of this paper is to make that missing part of HRO more visible, to be of greater help to the neonatal community, and to introduce readily adopted measures that man an organization toward High Reliability.  (06/2020) (link)
• van Stralen, Daved, Sean D. McKay, Kenji Inaba, Mark Hartwig, and Thomas A. Mercer. Comment on "A tactical medicine after-action report of the San Bernardino terrorist incident". Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 19(5):825-26, 2018. There is more to an active shooter incident than medicalcare and law enforcement activity. We identified elements of high reliability organizing; interactive, real-time risk assessment and management; leadership in extremis with leader-leader constructs; proactive critical incident stress management; visual communication with heedful interrelating; and self-organizing improvisation. (07/2018) (link)
• Neeki MM, Dong F, Toy J, Vara R, Jabourian N, Jabourian A, Wong D, Vaezazizi R, Seiler K, Pennington TW, Powell J, van Stralen D, Culhane JT, Borger R. Efficacy and safety of TXA in prehospital traumatic hemorrhagic shock; outcomes of the Cal-PAT study. Western Journal of Emergency Medicine. 18(4): 673-83, 2017. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess thesafety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the framework of North American emergency medicine standards and protocols.  (04/2017) (link)
• Braun BI, Longo BA, Chitavi S, Kusek L, Wagner L, Daved van Stralen D, Patterson Burdsall D, Vance JF, Lona Mody L, Clancy MF, Donofrio KM, Yendro S. IDENTIFYING HIGH RELIABILITY PRACTICES FOR INFECTION PREVENTION IN LONG-TERM CARE, PART 2: PRACTICES FROM THE FIELD. Annals of Long-Term Care: Clinical Care and Aging. 25(2):13, 2017 Although concepts of high reliability are promoted widely in acute care, little is known about the extent to which the core processes of high reliability have been applied to infection prevention practices in nursing homes and assisted living facilities. In a previous article, the authors reported use of high reliability concepts in current literature and national initiatives. To further identify practical strategies of high reliability organizing that could be applied to nursing facilities, the authors dispatched a call for practices to long-term care facilities (LTCFs) regarding their current infection prevention practices. Then, authors convened an expert, roundtable panel to evaluate the facility responses. After identifying practice examples consistent with high reliability principles, authors then created an education module presenting examples that can be applied to infection prevention in LTCFs. (03/2017)
• Braun BI, Longo BA, Chitavi S, Kusek L, Wagner L, van Stralen D, Burdsall DP, Vance JF, Mody L, Clancy MF, Donofrio KM, Yendro S. Identifying High Reliability Practices for Infection Prevention in Long-Term Care Part 1. Annals of Long-Term Care: Clinical Care and Aging. 25(1):29-35, 2017. Though concepts of high reliability are promoted widely in acute care, little is known about the extent to which core processes of high reliability have been applied, directly or indirectly, to infection prevention in nursing homes and assisted living facilities. In this review, we sought to identify examples of effective or innovative infection prevention practices from published literature and existing national initiatives that are consistent with core processes of high reliability. We first detail the five core processes of high reliability and their applicability to long-term care and then discuss our findings from the literature. Although high reliability is an unfamiliar term, we found that examples of core processes are already directly or indirectly being applied and related strategies have been incorporated into national initiatives. (01/2017)
• van Stralen, Daved,  Kissel Shanna. Physiological Pediatrics: An all-encompassing refresher on pediatrics. Journal of Emergency Medical Services, 2016; 41(7): 46-57. Invited The smaller and incompletely developed organ systems found in infants and children, necessary to facilitate birth, can create diseases and medical conditions not found in adults, affect the child’s physiologic ability to respond to illness or injury, and influence pediatric therapeutic modalities. This can perplex medical caregivers not trained in pediatrics and lead to missed diagnoses, inadequate medical treatment or marginalization of care. Rather than develop parallel systems for children and adults, appreciation of these anatomic and physiologic changes can help translate what is familiar—adult medical conditions, diagnostics and therapies—to the treatment of children.  (07/2016)
• van Stralen, Daved [guest editor]. The Organization's Response to Ambiguous Information [Special Issue]. Journal of Contingencies and Crisis Management 23(2):47-123, 2015. Invited Review by diverse authors regarding the effect of ambiguous information on organizational performance and operations. (06/2015)
• van Stralen, Daved, Thomas A. Mercer. Ambiguity in the Operator’s Sense. Journal of Contingencies and Crisis Management. 23(2):47-53, 2015. Invited Ambiguity is a central problem for operators working in dynamic, high-risk environ- ments. Operators must decide on a course of action before knowing with certainty how the system will respond.Though ambiguity is expected, how it presents is unexpected.We reduce ambiguity when we can give meaning to information and events through use of context, responsiveness of the system, and when we can view events from a higher level. Preparation and training for routine operations helps identify potential ambiguities before events begin.The experienced operator engages the situation relying on real-time experience to learn what works through action, thus further reducing ambiguity.  (06/2015) (link)
• van Stralen Daved. Ambiguity [editorial]. Journal of Contingencies and Crisis Management. 23(2):54-58, 2015.  Ambiguity may lead us to construct a world that, while supported by evidence, is not true. This is the danger of ambiguity – we select evidence and interpretations for their plausibility, but later events show we were wrong.  (06/2015) (link)
• Flitter Mark A., Kelly R. Riesenmy, Daved van Stralen. Current Medical Staff Governance and Physician Sensemaking: A Formula for Resistance to High Reliability. Advances in Health Care Management, 13:3-28, 2012. (11/2013)
• van Stralen, Daved, Thomas A. Mercer. EMS and high reliability organizing: Achieving safety and reliability in the dynamic, high-risk environment. Journal of Emergency Medical Services. 38(6):60-63, 2012. Invited Methods developed for US Naval Aviation and aircraft carrier flight operations, codified as the High Reliability Organization, can improve operations in the time-compressed, austere, hazardous environment of EMS. (06/2012)
• van Stralen Daved. The Origins if EMS in Military Medicine: How combat medicine influenced the advent of today’s EMS model. Journal of Emergency Medical Services, 34(9): 11-15, 2008. Invited  (09/2008)
• van Stralen D, Calderon R, Lewis J, Roberts KH. Changing a pediatric sub-acute facility to increase safety and reliability. Advances in Health Care Management, 7:259-282, 2008. Invited  (03/2008)
• van Stralen, Daved. High Reliability Organizations: Changing the Culture of Care in Two Medical Units. Design Issues 24(1): 78-90, 2008. Invited Changing the culture of care in the Pediatric Intensive Care Unit and a Pediatric Subacute Care Facility through use of high reliability techniques. These methods served organizational design for the development of a pediatric intensive care unit and the transformation of a pediatric subacute care facility into a chronic intensive care unit. (01/2008)
• van Stralen, Daved, Gary Provansal. The French connection: France's wildland fire service finds success through high reliability concepts. Wildland Firefighter 11(3): 26-34, 2007. Invited Description of French wildland firefighting techniques and equipment including the use of HRO techniques. Also, a description of their national wildland firefighting simulation program. (03/2007)
• D van Stralen. "Leadership for Resilience." National Wildlife Preserve Fire Management . (2006): CD. Use of leadership for resilience when encountering the unexpected. (12/2006)
• Roberts K, Madsen P, Desai V, van Stralen D. A case of birth and death of a high reliability healthcare organization. Quality Safety Health Care, 14(3): 216- 220, 2005.  (03/2005)
• Perkin RM, van Stralen D. Twenty things you may not know about pediatrics. Journal of Emergency Medical Services, 25(3): 50-64, 2000.  (03/2000)
• Perkin RM, van Stralen D. Pitfalls in pediatric airway management. Journal of Emergency Medical Service, 25(3): 38-49, 2000.  (03/2000)
• van Stralen DW, Perkin RM. Adolescence 101: An EMS primer on teenage development and behavior. Journal of Emergency Medical Services, 24(3): 58-76, 1999. Invited  (03/1999)
• Perkin RM, van Stralen DW. My child can’t breathe: New tools for the recognition and early management of pediatric respiratory failure. Journal of Emergency Medical Services, 24(3): 43-56, 1999. (03/1999)
• McConnell, Mark, Daved van Stralen. Emergency medical decision-making in the tactical environment. The Tactical Edge (National Tactical Officers Association). 15(3):32-39, 1997.  The tactical environment differs markedly from  Emergency Medical Services or hospital settngs where medical care is ordinarily rendered. Much has been written on the mechanics of Tactical Emergency Medical Services (TEMS). The techniques of providing medical care in the tactical environment have been covered well in courses like the CONTOMS Tactical EMT course. However very little information on the decision making processes that effect performance and patient care in the tactical environment has been given to the TEMS provider. We discribe methods for medical decision making in the tactical environment.  (06/1997)
• Perkin RM, van Stralen D. Pitfalls in pediatric airway management. Pediatric Emergency Medicine Reports, 22(2): 91-102, 1997.  (02/1997)
• Woestman R, Perkin R, van Stralen D. The black widow: Is she deadly to children? Pediatric Emergency Care, 12(5): 360-364, 1996.  (05/1996)
• Perkin R, van Stralen D, Mellick L. Managing pediatric airway emergencies: Anatomic considerations, alternative airway and ventilation techniques, and current treatment options. Emergency Medicine Reports, 1(1): 1-11, 1996.  (01/1996)
• van Stralen D, Perkin R. Retrograde intubation: Difficulty in an 18-year-old muscular dystrophy patient. American Journal Emergency Medicine, 13(1): 100-101, 1995.  (01/1995)
• van Stralen D, Rogers M, Perkin R, Fea S. Retrograde intubation training using a mannequin. American Journal Emergency Medicine, 13(1): 50-52, 1995.  (01/1995)
• DeNicola L, Kleid D, Brink L, van Stralen D, Scott M, Gerbert D, Brennan L. Use of pediatric physician extenders in pediatric and neonatal intensive care units. Critical Care Medicine, 22: 1856–1864, 1994.  (07/1994)
• Simmons M, Johnson E, Perkin RM, van Stralen DW. Intraosseous extravasation complication: Case reports. Annals Emergency Medicine, 23(2): 363–366, 1994. (02/1994)
• Swift J, Barruga M, Perkin R, van Stralen D. Respiratory failure complicating rubeola. Chest, 104(6): 1786-1787, 1993.  (06/1993)
• Perkin RM, van Stralen D. Resuscitating Pediatric Cardiac Arrest Victims: Facts and Dilemmas. Journal Emergency Medical Services, 17(6):68–73, 1992. (06/1992)
• Jansen PW, Perkin RM, van Stralen D. Mojave rattlesnake envenomation: prolonged neurotoxicity and rhabdomyolysis. Annals Emergency Medicine, 121(3):322–325, 1992. (03/1992)
• Ashwal, Stephen, R Perkin, JR Thompson, LG Tomasi, Daved van Stralen, S Schnieder. Cerebral Blood Flow (CBF) & CBF/PCO2 reactivity in Childhood Strangulation. Pediatric Neorology 7(5):369-374, 1991.   (05/1991)
• Perkin RM, van Stralen D. Shock in the Pediatric Patient. Journal Emergency Medical Services, 15: 58-73, 1990. (05/1990)
• Branson HE, van Stralen D, Schottinger J, Peters W, Endo Y. . A practical heparin reduction algorithm: Execution and operational characteristics. Journal Clinical Pathology, 38(4): 422-427, 1985. A limited pilot study has been made of a newly devised heparin reduction algorithm  (HRA). This formulation is a derivative of the alternative surveillance plan known as the activated partial thromboplastin time after heparin removal (aPTT/HR) scheme Unlike the traditional plan, the HRA is the first approach to provide information about the individual and collective pharmacological effects of heparin and coumarins when the drugs are administered simultaneously. In this feasibility study the HRA was used without incident in six patients every 24 h to calculate the trend of the evolving anticoagulant effect of coumarin. The computations provided by a laboratory based data management group permitted the clinician to titrate precisely the withdrawal of heparin in response to the daily fluctuations in coumarin effect. In this way, the activated partial thromboplastin time could always be maintained within the desired therapeutic interval. Three divergent patient experiences are presented to demonstrate the operational characteristics and responsiveness of the new HRA plan. (04/1985)

Non-Scholarly Journals

• van Stralen, Daved. Anti-racism in medical school. Los Angeles Times August 4, 2021. [letter] Physicians believe they do not lower the quality of care for anybody. Their intention keeps them from seeing gaps in care. Enough gaps become a pattern that we accept as normal. Our intention to give good care becomes knowledge that we give good care. I served on a fire rescue ambulance in South Los Angeles 10 years after the Watts riots. People of color have justified reasons to not trust authority. hey have cultural experiences and words out of reach of white physicians. (08/2021)
• van Stralen, Daved. "Thank her for me." Dear Annie syndicated column December 22, 2006. (12/2006)
• van Stralen, Daved. "Rudeness is Power." Los Angeles Times (page F6) April 4, 2004. (04/2004)

Books and Chapters

• Van Stralen, Daved, Spencer Byrum and Bahadir Inozu. 2017. “High Reliability for a Highly Unreliable World: Preparing for Code Blue through Daily Operations in Healthcare.” North Charleston, SC: CreatSpace Publishing. Apractical definition of High Reliability Organization (HRO) has been elusive. The name itself is somewhat divisive, as if an organization strives for low reliability. It is well accepted that an HRO operates in an environment of risk factors and complexity where we would expect severe accidents, if not catastrophic failure. After that, the definition becomes less explicit: the HRO does not experience such events, avoids these events, or has no errors. Left unanswered, is “Why would an organization enter such an environment?” (12/2017)
• Van Stralen, Daved, McKay, S.D., Williams, G.T. and Mercer, Thomas A., Tactical Improvisation: After-Action/Comprehensive Analysis of the Active Shooter Incident Response by the San Bernardino City Fire. Invited The charge to the investigative team in developing this After-Action Report (AAR) was as follows: First, to perform a gap analysis between guidelines, training and the demands of this specific incident. Second, to offer recommendations for improvement and to identify lessons learned. This After-Action Report is specific to the fire service functions of fire, rescue, and EMS. It will, however, examine overlapping functions for an incident where circumstances brought the missions of law enforcement and the fire department personnel together. This AAR also describes the actions of mutual aid agencies that supported rescue, EMS, ICS, and IMT (12/2017)
• Roberts K, Yu K, van Stralen D. Patient Safety is an Organizational Systems Issue: Lessons from a Variety of Industries. Youngberg BJ (ed). The Patient Safety Handbook, Second Edition. Burlington, MA: Jones & Bartlett Publishing. 2013. Invited (11/2013)
• Roberts KH, Kuo Y, van Stralen D. Patient Safety as an Organizational Issue: Lessons from a variety of Industries. Youngberg BJ and Hatlie MJ (eds). The Patient Safety Handbook. Burlington, MA: Jones & Bartlett Publishing. 2004. Invited (11/2004)
• Perkin RM, van Stralen D. Bag-valve-mask ventilation. Perkin RM, Swift JD, Newton DA (eds). Pediatric Hospital Medicine: Textbook of Inpatient Management, Philadelphia, PA: Lippincott Williams & Wilkins. 2003. Invited (11/2003)
• Perkin RM, van Stralen D. Intubation. Perkin RM, Swift JD, Newton DA (eds). Pediatric Hospital Medicine: Textbook of Inpatient Management. Philadelphia, PA: Lippincott Williams & Wilkins. 2003. Invited (11/2003)
• van Stralen D, Perkin RM. General pediatric versus adult patient considerations. Zimmerman JL (ed). Fundamental Critical Care Support, Third Edition. Mt. Prospect, IL: Society of Critical Care Medicine. 2001. Invited (11/2001)
• Perkin RM, van Stralen D. Airway Management. Borker G (ed). Textbook of Adult and Pediatric Emergency Medicine. Atlanta GA: American Health Consultants. 2000. Invited (11/2000)
• van Stralen D, Perkin RM. Pediatric physiology in critical care. Dellinger PR (ed). Fundamental Critical Care Support. Anaheim, CA: Society of Critical Care Medicine. 1999. Invited (11/1999)
• van Stralen D, Perkin R. Oxygen delivery techniques. Dieckmann R, (ed). Illustrated Textbook of Pediatric Emergency and Critical Care Techniques Philadelphia: Mosby-Year Book, Inc. 1997. Invited (11/1997)
• Perkin R, van Stralen D. Intraosseous access and infusion. Taeusch HW, Christiansen R, Bueschler ES, and Hughes WT (eds). Pediatric and Neonatal Tests and Procedures. Orlando, FL: W. B. Saunders Co, 1996. Invited (11/1996)
• Hazinski MF, van Stralen D. Physiologic and anatomic differences between children and adults. Levin D and Morriss F (eds). Essentials of Pediatric Intensive Care. Quality Medical Publishing, 1990. Invited (11/1990)

Abstract

• van Stralen, Daved, Ted Westmoreland. Management of a mechanical ventilator using patient calm as an endpoint. 2014 Special Operations Medical Association Scientific Assembly (SOMSA), December 8-11, 2014, Tampa, Florida Special Operations Forces (SOF) may use mechanical ventilators in operational and austere settings. In the intensive care unit ICU) the settings for mechanical ventilation (MV) are guided by blood gas analysis and Patient-Ventilator Asynchrony (PVA) is commonly managed using drugs. However, long-term care facilities manage ventilator-dependent patients without the use of drugs or blood gas analysis and their methods may be useful for SOF. (12/2014)
• van Stralen, Daved, Ted Westmoreland. Use of a visual five-point respiratory exam to evaluate breathing in the operational area. 2014 Special Operations Medical Association Scientific Assembly (SOMSA), December 8-11, 2014, Tampa, Florida We describe a case of a soldier with upper airway obstruction from an explosion where a delay establishing a surgical airway occurred because of difficulty evaluating the functional status of the airway. We then describe how a rapid, visual five-point respiratory exam can be used operationally.  (12/2014)
• (PEER REVIEWED) D Christianson, P Nasiatka, D Thomas, D van Stralen. "High Reliability Organizing (HRO) in Wildland Fire." . (2006): -. (06/2006) (link)
• van Stralen D, Calderon R, Clements P, Kausen B, Padgett J, Daniel A, Rao R. Use of the Boyd OODA Loop to Initiate Mechanical Ventilation (IMV) in a Chronic Intensive Care Nursing Home. AMDA 29th Annual Symposium Mastering the Challenges Across the Spectrum of Long-Term Care March 16-19, 2006, Dallas, Texas. The Chronic Intensive Care Facility (CICF) fuses Long-Term Care (LTC) objectives and methods with those of the Intensive Care Unit (ICU). This results in a medically austere environment which can safely meet the needs of the patient in a way that neither program can. CICFs may not have laboratory support for rapid blood gas determination or chest radiographs. Regulations may limit use of chemical sedation or disallow protocols. The Boyd OODA loop and use of structured problem solving can facilitate provision of chronic intensive care in a nursing home environment. Tracheostomy-dependent patients may develop respiratory distress or failure to the degree that mechanical ventilation is indicated. This can be accomplished by referral to an ICU or to the Emergency Department (ED) through the Emergency Medical Services (EMS) system. We describe our experience using the Boyd OODA loop to manage respiratory failure and IMV. For decision making we use the method of John Boyd, Col. USAF (ret.), who developed the OODA loop for aerial combat during the Viet Nam War (Coram). The OODA Loop represents a rapid, loop decision process of Observe the situation, Orient to objectives in the context of the organization’s culture within the limits of human performance, Decide on an action, Act, and then loop to observe the response to that action. (03/2006)
• van Stralen D, Calderon R, Padgett J, Clements P, Lawson E, Daniel A, Rao R, Eachus T. Smile and Laughter During Mechanical Ventilation in Children. AMDA 29th Annual Symposium March 16-19, 2006, Dallas, Texas. Mechanical ventilation (MV) has a reputation for causing distress and anxiety. We report the presence of smile and laughter which are important human social interactions in children receiving long-term MV. We found no relationship between PEEP and smile. The childrenwith the highest PEEP (8 and 9 cm of water) all smiled. Ventilatorrates used in the intensive care unit tend to be low, usually under20 breaths per minute. Low ventilator rates tend to be saferbecause when disconnections occur the patient may continue tobreathe. We use higher ventilator rates because from our experience the children smile and play more. This follows because physical activity requires a higher respiratory rate. Smile is an important part of human interaction. It promotes interaction between people and to some degree can justify life. Moral judgments about the profoundly handicapped patient develop regarding their quality of life or even their right to life. (03/2006)
• van Stralen D, Calderon R, Clements P, Daniel A, Rao R, Padgett J, Kausen B, Roberts K. High Reliability Organization Methods Facilitate Initiation of Mechanical Ventilation in A Pediatric Nursing Home.: 111-S. Critical Care Medicine, 33(12), A28.  Society of Critical Care Medicine’s 35th Critical Care Congress, San Francisco, California. January 7-11, 2006. (01/2006)
• D van Stralen, D Sorensen, R Calderon, J Padgett, S Klein, P King, A Daniel, M HArris, R Rao. "Fluid Bolus Therapy to Treat Thick Secretions in Ventilator-Dependnet Children." International Conference on Home Mechanical Ventilation . (2005): 61. (04/2005)
• van Stralen D, P Clements, R Calderon, L Meissner, D pAdgett, R Rao. "Use of a clinical respiratory exam to adjust mechanical ventilators in ventilator-dependent children." International Conference on Home Mechanical Ventilation . (2005): 61. (04/2005)
• van Stralen D, Calderon R, Meissner L, King P, Lewis J, Padgett D, Abd-Allah S, Rao R. Intensive care unit support for a freestanding pediatric subacute care facility. CHEST 2002 San Diego, CA presented November 4-7, 2002. CHEST 2002;122 (4 suppl): 1535. (11/2002)
• van Stralen D, Calderon R, King P, Gil M, Meissner L, Rao R. Stability of intensive care unit mechanical ventilator settings in a subacute care facility. CHEST 2002 San Diego, CA November 4-7, 2002. CHEST 2002; 122 (4 suppl). (11/2002)
• van Stralen D, Calderon R, King P, Padgett D, Lewis J, Rao R. Initiation of mechanical ventilation in a pediatric subacute facility vs. Intensive care unit: Cost avoidance. CHEST 2002 San Diego, CA presented November 4-7, 2002. CHEST 2002; 122 (4 suppl):1165 . We began initiation of MV in our Subacute Care Facility (SCF) for the treatment of acute respiratory failure in preparation for transport to the emergency department for further treatment and admission to ICU. We found that these children quickly stabilized, obviating the need for transport. Because of regulatory limitations of sedation in the nursing home, we managed MV by adjusting settings for the comfort of the child without the use of chemical sedation. Later, we identified early heralds of impending respiratory failure which allowed for initiation of MV earlier in the course of disease when interventions are safer and more effective. Additional reimbursement from third-party payors covered this new, higher level of care. An unexpected finding was significant cost avoidance to the medical care delivery system and society. An organizational behavior model supporting the bedside caregiver is an effective method to initiate MV for acute respiratory failure. An incidental finding was a decrease in transfers to the acute care hospital and subsequent cost avoidance to the medical system. (11/2002)
• van Stralen D, Calderon R, King P, Lewis J, Padgett D, Nydam D, Rao R. An unrecognized resource for bioterrorism response: Subacute care mechanical ventilation management. CHEST 2002 San Diego, CA November 4-7, 2002. CHEST 2002; 122 (4 suppl): 1585. (11/2002)
• van Stralen D, Gil M, Lewis J, King P, Calderon R, Rao R. Role of nursing facilities in a local disaster: Emergency admissions. J American Medical Directors Association 2002; 2 (2): A19 (AMDA 25th Anniversary Symposium, Dan Diego, CA March 21-24, 2002) (03/2002)
• van Stralen D, King P, Lewis J, Calderon R, Castello S, Rao R, Padgett D, Abd-Allah S. Intensive care unit support for a freestanding pediatric subacute facility. J American Medical Directors Association 2002; 3(2): A18 (AMDA 25th Anniversary Symposium, San Diego, CA March 21-24, 2002). (03/2002)
• van Stralen D, Daniel A, Calderon R, Rao R. Management of thick tracheal secretions with an oral rehydration regimen. J American Medical Directors Association 2002; 3(2): A19 (AMDA 25th Anniversary Symposium, San Diego, CA March 21-24, 2002). (03/2002)
• Applegate R, van Stralen D, Calderon R, Newsom H. Use of a five-point respiratory exam for treating patients. CHEST 2001; 120(4): 252S (November 7, 2001). (11/2001)
• King P, van Stralen D, Padgett D, Newsom H, Petersen F, Daniel A Rao R. Change in referral patterns for a pediatric subacute facility. Journal of American Medical Director’s Association 2001; 2(2). (02/2001)
• Woestman R, Perkin R, Serna T, Van Stralen D, Knierim D. Mild head injury in children: identification, clinical evaluation, neuroimaging, and disposition. Journal of Pediatric Health Care, 12(6) 288-298, 1998.  (06/1998)
• Hilton T, Grainger M, Perkin R, van Stralen D. Bilevel positive pressure ventilation via tracheostomy in the home setting: A viable option for the pediatric patient. Chest 1998; 114(4): 256S. (04/1998)
• van Stralen D, Goss J. Damage control for pediatric spinal injuries. Journal Emergency Medical Services, 23(3): 114-126, 1998.  (03/1998)
• Perkin R, Orr R, Ashwal S, Hilton T, van Stralen D. Long-Term Ventilation (LTV) in Children with Severe Central Nervous System Impairment. Presented at 6th International Conference on Home Mechanical Ventilation, Lyon France, March 6, 1997. (03/1997)
• Jansen P, Vannix R, van Stralen D, Perkin R. Predictors of mortality in pediatric transport patients. Crit Care Med 1995; 23(1 suppl): A201. (11/1995)
• van Stralen D, Lake C, Perkin R. Success and complication rates in pediatric intubation by paramedics following a one-hour training session. Crit Care Med 1995; 23(1 suppl): A203. (11/1995)
• Rogers M, Scott R, Malinowski T, Langa L, Abd-Allah S, Perkin R, van Stralen D. Volume accuracy of the Siemens Servo 900C and Novametrix ventrak when delivering helium-oxygen mixtures. Respiratory Care 40:1206, 1995. (11/1995)
• van Stralen D, Vannix R. Young T, Zirkle T, Perkin R, Boswell B, McKee M, Martin J, Camp D. Preparations for a civil disturbance by a civilian pediatric transport team. Prehospital Disaster Med 1994; 9(suppl 1): S56. (09/1994)
• Jansen P, Vannix R, van Stralen D, Perkin R: Use of PALS skills in the transport of 650 pediatric patients. Crit Care Med 1994; 221(1): A151. (01/1994)
• Johnson L, van Stralen D, Perkin RM. Unstable vertebral fractures without spinal cord injury in uncooperative trauma patients. Prehospital Disaster Med. 1992; 17 (S1): 14. (11/1992)
• van Stralen D, Perkin RM, Barruga M, Muellar B, McKee M, Garvin S. Decrease in Quality of CPR Chest Compressions During Patient Transport, Prehosp Disaster Med. 1992; 7(S1): 27. (11/1992)
• van Stralen D, Rogers M, Perkin RM, Fea S. Performance of non-physicians performing retrograde intubation. Prehospital Disaster Med. 1992; 17 (S1): 29. (11/1992)
• Downey R, Perkin RM, Gold PM, van Stralen D, MacQuarric J. The efficiency of nasal continuous positive airway pressure in the management of obstructive sleep apnea in children. Sleep Research 20:237, 1991. (11/1991)
• Downey R, Perkin RM, Gold P, van Stralen D. Nasal Continuous Positive Airway Pressure in Children with Obstructive Sleep Apnea Clinical Research 39: 111A, 1991. (11/1991)
• Swift JD, Burruga MC, Perkin RM, van Stralen D. Respiratory Failure Complicating Rubeola. Chest 100: 16 S, 1991. (11/1991)
• Downey R, Perkin R, Elmendorf E, Hardesty R, Gold PM, van Stralen D. Nasal CPAP efficacy in infants and children with obstructive sleep apnea. Pediatr Pulmonal 11:370, 1991. (11/1991)
• Swift JD, Barruga MC, Perkin RM, van Stralen D. Respiratory Failure Complicating Rubeola. Clinical Research 39: 138A, 1991. (11/1991)

Scholarly Journals--Accepted

• van Stralen Daved, Perkin Ronald M. RSV: Not the common cold. Journal of Emergency Medical Services, 25(2):72-80, 2000. Invited (02/2000)
• Narasimhan N, van Stralen DW, Perkin RM. Acute supraglottitis caused by varicella. Pediatric Infectious Disease Journal, 12(7):69–70, 1993. (07/1993)