const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.title = "Communication Skills in Clinical Anaesthesia";
pres.author = "Department of Anaesthesia";
pres.subject = "Communication in Anaesthetic Practice";

// ─── COLOUR PALETTE ──────────────────────────────────────────────────────────
// Deep navy dominates, steel-blue accent, warm amber highlight, clean white text
const C = {
  navy:      "0A1931",   // dominant dark bg
  navyMid:   "112244",   // slightly lighter section bg
  steel:     "2D6A9F",   // accent shapes, headers
  steelLight:"3A89CC",   // lighter blue highlights
  amber:     "E8A020",   // warning / call-out accent
  amberLight:"F5C842",   // sub-accent
  white:     "FFFFFF",
  offWhite:  "F0F4F8",
  slate:     "8BA4BE",   // muted text / sub-bullets
  darkSlate: "1C2E45",   // card bg
  green:     "2ECC71",   // positive / good practice
  red:       "E74C3C",   // barriers / pitfalls
  lightGrey: "D8E6F3",
};

// ─── HELPER FUNCTIONS ─────────────────────────────────────────────────────────

function sectionBanner(slide, text) {
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      fontSize: 13, color: C.slate,
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}

function bulletBox(slide, items, opts = {}) {
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    x = 0.4, y = 1.7, w = 12.5, h = 5.3,
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}

function addCard(slide, x, y, w, h, title, body, titleColor = C.steel, bgColor = C.darkSlate) {
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    x, y, w, h,
    fill: { color: bgColor },
    line: { color: titleColor, pt: 1.5 },
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    fontSize: 12, bold: true, color: titleColor,
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    fontSize: 11, color: C.offWhite,
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function pageNumber(slide, num, total) {
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    x: 11.8, y: 7.15, w: 1.3, h: 0.25,
    fontSize: 8, color: C.slate, align: "right", margin: 0,
  });
}

// ─── SLIDE DEFINITIONS ───────────────────────────────────────────────────────
const TOTAL = 27;

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };

  // Large accent bar left
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    x: 0, y: 0, w: 0.45, h: 7.5,
    fill: { color: C.steel }, line: { type: "none" },
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    x: 0.45, y: 0, w: 0.15, h: 7.5,
    fill: { color: C.amber }, line: { type: "none" },
  });

  s.addText("COMMUNICATION SKILLS", {
    x: 0.85, y: 1.6, w: 11.5, h: 0.8,
    fontSize: 40, bold: true, color: C.white,
    charSpacing: 2, fontFace: "Calibri",
  });
  s.addText("IN CLINICAL ANAESTHESIA", {
    x: 0.85, y: 2.45, w: 11.5, h: 0.8,
    fontSize: 40, bold: true, color: C.amber,
    charSpacing: 2, fontFace: "Calibri",
  });
  s.addShape(pres.ShapeType.line, {
    x: 0.85, y: 3.4, w: 10, h: 0,
    line: { color: C.steelLight, pt: 1.2 },
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  s.addText("A Comprehensive Framework for Consultant Anaesthetists", {
    x: 0.85, y: 3.55, w: 11.5, h: 0.4,
    fontSize: 16, color: C.slate, italic: true, fontFace: "Calibri",
  });
  s.addText("Covering: Team Communication · Patient Communication · Crisis Communication · Handover", {
    x: 0.85, y: 4.05, w: 11.5, h: 0.35,
    fontSize: 12, color: C.steelLight, fontFace: "Calibri",
  });
  s.addText("Department of Anaesthesia  ·  " + new Date().getFullYear(), {
    x: 0.85, y: 6.8, w: 8, h: 0.3,
    fontSize: 10, color: C.slate, fontFace: "Calibri",
  });
  pageNumber(s, 1, TOTAL);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — AGENDA
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Overview");
  slideTitle(s, "Agenda", "A structured deep-dive across all communication domains");
  accentLine(s);
  pageNumber(s, 2, TOTAL);

  const sections = [
    { num: "01", title: "Why Communication Matters in Anaesthesia", y: 1.7 },
    { num: "02", title: "Frameworks & Models", y: 2.4 },
    { num: "03", title: "Pre-operative Patient Communication & Consent", y: 3.1 },
    { num: "04", title: "Intra-operative Team Communication", y: 3.8 },
    { num: "05", title: "Closed-Loop Communication & SBAR", y: 4.5 },
    { num: "06", title: "Crisis Resource Management (CRM) Communication", y: 5.2 },
    { num: "07", title: "Perioperative Handover", y: 5.9 },
    { num: "08", title: "Breaking Bad News & Difficult Conversations", y: 6.6 },
  ];

  // Right column
  const sectionsR = [
    { num: "09", title: "Barriers to Effective Communication", y: 1.7 },
    { num: "10", title: "Hierarchy, Power & Psychological Safety", y: 2.4 },
    { num: "11", title: "Electronic & Written Communication", y: 3.1 },
    { num: "12", title: "Communication in Specific Contexts", y: 3.8 },
    { num: "13", title: "Measuring & Improving Communication", y: 4.5 },
    { num: "14", title: "Simulation-Based Communication Training", y: 5.2 },
    { num: "15", title: "Medico-legal Dimensions", y: 5.9 },
    { num: "16", title: "Summary & Key Takeaways", y: 6.6 },
  ];

  sections.forEach(sec => {
    s.addText(sec.num, {
      x: 0.35, y: sec.y, w: 0.5, h: 0.32,
      fontSize: 11, bold: true, color: C.amber, margin: 0, fontFace: "Calibri",
    });
    s.addText(sec.title, {
      x: 0.9, y: sec.y, w: 5.7, h: 0.32,
      fontSize: 12, color: C.offWhite, margin: 0, fontFace: "Calibri",
    });
  });
  sectionsR.forEach(sec => {
    s.addText(sec.num, {
      x: 6.8, y: sec.y, w: 0.5, h: 0.32,
      fontSize: 11, bold: true, color: C.amber, margin: 0, fontFace: "Calibri",
    });
    s.addText(sec.title, {
      x: 7.35, y: sec.y, w: 5.7, h: 0.32,
      fontSize: 12, color: C.offWhite, margin: 0, fontFace: "Calibri",
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — WHY COMMUNICATION MATTERS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 01 · Why Communication Matters");
  slideTitle(s, "The Case for Communication", "Evidence from patient safety & incident analysis");
  accentLine(s);
  pageNumber(s, 3, TOTAL);

  // Stat cards
  const cards = [
    { x: 0.35, val: "70%", label: "of adverse events involve communication failure as a contributing factor (JCAHO sentinel event data)", col: C.red },
    { x: 3.55, val: "~1:100,000", label: "anaesthetic mortality rate — yet communication failures remain among top contributory causes", col: C.amber },
    { x: 6.75, val: "#1", label: "Communication breakdown is the leading root cause in anaesthetic critical incidents (AIMS database)", col: C.steelLight },
    { x: 9.95, val: "3x", label: "higher likelihood of adverse events when handover communication is substandard", col: C.green },
  ];
  cards.forEach(c => {
    s.addShape(pres.ShapeType.roundRect, {
      x: c.x, y: 1.85, w: 2.95, h: 2.8,
      fill: { color: C.darkSlate }, line: { color: c.col, pt: 2 }, rectRadius: 0.1,
    });
    s.addText(c.val, {
      x: c.x + 0.1, y: 1.95, w: 2.75, h: 0.75,
      fontSize: 28, bold: true, color: c.col, align: "center", fontFace: "Calibri", margin: 0,
    });
    s.addText(c.label, {
      x: c.x + 0.1, y: 2.75, w: 2.75, h: 1.75,
      fontSize: 11, color: C.offWhite, wrap: true, fontFace: "Calibri", margin: 4,
    });
  });

  s.addText("Communication is a core clinical competency — not a soft skill. It is directly linked to patient outcomes, team performance and medico-legal accountability.", {
    x: 0.35, y: 4.95, w: 12.6, h: 0.5,
    fontSize: 13, color: C.amberLight, italic: true, bold: true,
    fontFace: "Calibri", align: "center",
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — ANAESTHESIA NON-TECHNICAL SKILLS (ANTS)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 02 · Frameworks & Models");
  slideTitle(s, "Anaesthetists' Non-Technical Skills (ANTS)", "The validated behavioural marker system for anaesthesia practice");
  accentLine(s);
  pageNumber(s, 4, TOTAL);

  addCard(s, 0.35, 1.75, 5.9, 2.5,
    "🧭 ANTS — 4 Core Categories",
    "Task Management · Team Working · Situation Awareness · Decision Making\n\nDeveloped at University of Aberdeen (Fletcher et al., 2003). Validated against anaesthetic practice in real theatres.",
    C.steelLight, C.darkSlate);

  addCard(s, 6.55, 1.75, 6.5, 2.5,
    "💬 Team Working — Communication Sub-elements",
    "• Exchanging information clearly and concisely\n• Establishing shared understanding\n• Coordinating activities with team members\n• Using appropriate assertiveness\n• Supporting others through communication",
    C.amber, C.darkSlate);

  addCard(s, 0.35, 4.5, 12.6, 2.6,
    "🔑 Key Principle",
    "ANTS emphasises that communication is embedded within ALL four categories — not siloed. Situation awareness depends on information exchange; decisions require shared mental models; task management requires explicit coordination. Communication failures therefore cascade across every domain.",
    C.green, C.darkSlate);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — CRM FOUNDATIONS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 02 · Frameworks & Models");
  slideTitle(s, "Crisis Resource Management — Origins & Principles", "Adapted from aviation Crew Resource Management by Gaba et al. (Stanford, late 1980s)");
  accentLine(s);
  pageNumber(s, 5, TOTAL);

  const principles = [
    { n: "01", t: "Know your environment", d: "Familiarity with equipment, personnel and layout reduces cognitive load during crises" },
    { n: "02", t: "Call for help early", d: "The most important determinant of outcome in a crisis — do not delay" },
    { n: "03", t: "Establish leadership", d: "Clear, acknowledged leadership prevents confusion and duplicated effort" },
    { n: "04", t: "Communicate clearly", d: "Closed-loop, directive communication — name + task + confirm receipt + report completion" },
    { n: "05", t: "Distribute workload", d: "Delegate tasks explicitly; avoid task fixation; monitor cognitive load of team members" },
    { n: "06", t: "Mobilise resources", d: "People, equipment, protocols — use ALL available resources proactively" },
    { n: "07", t: "Maintain shared mental model", d: "Verbalise your working diagnosis, plan and concerns so the whole team understands" },
    { n: "08", t: "Perform debriefing", d: "Structured hot and cold debriefs improve learning, reduce burnout and prevent recurrence" },
  ];

  const col1 = principles.slice(0, 4);
  const col2 = principles.slice(4);

  col1.forEach((p, i) => {
    const y = 1.8 + i * 1.2;
    s.addText(p.n, { x: 0.3, y, w: 0.45, h: 0.3, fontSize: 11, bold: true, color: C.amber, margin: 0 });
    s.addText(p.t, { x: 0.8, y, w: 5.7, h: 0.3, fontSize: 13, bold: true, color: C.offWhite, margin: 0 });
    s.addText(p.d, { x: 0.8, y: y + 0.32, w: 5.7, h: 0.72, fontSize: 11, color: C.slate, margin: 0, wrap: true });
  });
  col2.forEach((p, i) => {
    const y = 1.8 + i * 1.2;
    s.addText(p.n, { x: 6.8, y, w: 0.45, h: 0.3, fontSize: 11, bold: true, color: C.amber, margin: 0 });
    s.addText(p.t, { x: 7.3, y, w: 5.7, h: 0.3, fontSize: 13, bold: true, color: C.offWhite, margin: 0 });
    s.addText(p.d, { x: 7.3, y: y + 0.32, w: 5.7, h: 0.72, fontSize: 11, color: C.slate, margin: 0, wrap: true });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — PRE-OP PATIENT COMMUNICATION: PRINCIPLES
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 03 · Pre-operative Patient Communication & Consent");
  slideTitle(s, "The Pre-operative Consultation", "Building rapport, reducing anxiety and establishing trust");
  accentLine(s);
  pageNumber(s, 6, TOTAL);

  bulletBox(s, [
    { bold: "Preparation" },
    { sub: "Review notes, allergies, previous anaesthetic records BEFORE the consultation" },
    { sub: "Ensure a quiet, private environment — anxiety amplifies at the pre-assessment stage" },
    { bold: "Opening the consultation" },
    { sub: "Introduce yourself and your role clearly" },
    { sub: "Invite the patient's agenda first — 'What questions or concerns do you have about your anaesthetic?'" },
    { bold: "Information provision" },
    { sub: "Use teach-back: 'Can you tell me in your own words what will happen when you go to sleep?'" },
    { sub: "Provide written information to supplement verbal — leaflets reduce anxiety (RCoA guidance)" },
    { sub: "Avoid jargon; calibrate language to health literacy level" },
    { bold: "Assessing capacity & understanding" },
    { sub: "Mental Capacity Act (2005) — assume capacity, assess formally if in doubt" },
    { sub: "Four pillars: Understand · Retain · Weigh up · Communicate a decision" },
    { bold: "Closing" },
    { sub: "Summarise the plan, invite final questions, document the discussion" },
  ], { y: 1.75, h: 5.5, fontSize: 14 });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — INFORMED CONSENT
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 03 · Pre-operative Patient Communication & Consent");
  slideTitle(s, "Informed Consent in Anaesthetic Practice", "Montgomery v Lanarkshire (2015) changed the legal landscape");
  accentLine(s);
  pageNumber(s, 7, TOTAL);

  addCard(s, 0.35, 1.75, 5.9, 2.0,
    "⚖️ Post-Montgomery Standard",
    "A patient must be told of all material risks — a risk is material if a reasonable patient in their position would want to know about it, OR if this particular patient would want to know.\n\nThis is a PATIENT-centred standard, not a professional peer standard.",
    C.red, C.darkSlate);

  addCard(s, 6.55, 1.75, 6.5, 2.0,
    "📋 What Must Be Documented",
    "• Nature of anaesthetic technique(s) discussed\n• Alternatives offered (regional vs general, awake fibreoptic etc.)\n• Specific risks mentioned (PONV, dental damage, aspiration, awareness, death)\n• Patient's questions and responses\n• Capacity assessment if relevant",
    C.steelLight, C.darkSlate);

  addCard(s, 0.35, 4.0, 5.9, 2.8,
    "🗣️ Communicating Risk Effectively",
    "• Use absolute frequencies: '1 in 1000' not '0.1%'\n• Use visual aids where possible (frequency diagrams)\n• Contextualise: compare to everyday risks\n• Check the patient's pre-existing beliefs about risk\n• Personalise to the individual's comorbidities\n• Document explicitly what was discussed",
    C.amber, C.darkSlate);

  addCard(s, 6.55, 4.0, 6.5, 2.8,
    "⚠️ High-Risk Communication Scenarios",
    "• Paediatric consent / Gillick competence\n• Patients with cognitive impairment / dementia\n• Emergency surgery with limited time for discussion\n• Jehovah's Witnesses — blood products / advanced directives\n• Patients with English as second language — use qualified interpreters, NOT family members for consent discussions",
    C.amber, C.darkSlate);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — THEATRE TEAM COMMUNICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 04 · Intra-operative Team Communication");
  slideTitle(s, "The Theatre Team — Communication Roles & Dynamics", "Surgeon · Anaesthetist · Scrub nurse · ODP · Circulating nurse");
  accentLine(s);
  pageNumber(s, 8, TOTAL);

  bulletBox(s, [
    { bold: "Team composition & hierarchy" },
    { sub: "Theatre teams are multidisciplinary — each profession has distinct communication norms and expectations" },
    { sub: "Perceived hierarchy can suppress communication up the gradient (authority gradient)" },
    { sub: "Consultants must ACTIVELY invite input — create psychological safety for challenge" },
    { bold: "Pre-operative team brief (WHO Surgical Safety Checklist)" },
    { sub: "Sign-in · Time-out · Sign-out structure — mandated by WHO and NHS England since 2009" },
    { sub: "Shared mental model before incision reduces intra-operative communication failures by ~35%" },
    { sub: "Brief should include: patient ID, procedure, anaesthetic concerns, critical equipment, team introductions" },
    { bold: "Intra-operative communication patterns" },
    { sub: "Proactive updates: 'I'm planning to give X, please expect increased secretions'" },
    { sub: "Explicit task sharing: 'John, please draw up 10mg metoclopramide now'" },
    { sub: "Situation updates to the surgeon: blood loss, haemodynamic changes, airway concerns" },
    { bold: "Post-operative sign-out" },
    { sub: "Verify specimen labelling, equipment counts, concerns for recovery/ICU" },
  ], { y: 1.75, h: 5.5, fontSize: 13 });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — WHO SURGICAL SAFETY CHECKLIST
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 04 · Intra-operative Team Communication");
  slideTitle(s, "WHO Surgical Safety Checklist", "Structured communication framework — reducing mortality and complications worldwide");
  accentLine(s);
  pageNumber(s, 9, TOTAL);

  const checklistData = [
    [{ text: "SIGN IN (before induction)", options: { bold: true, color: C.white, fill: { color: C.steel } } },
     { text: "TIME OUT (before incision)", options: { bold: true, color: C.white, fill: { color: C.steel } } },
     { text: "SIGN OUT (before patient leaves theatre)", options: { bold: true, color: C.white, fill: { color: C.steel } } }],
    ["Patient identity confirmed\nConsent verified\nSite marked / not applicable\nAnaesthetic machine & medication check\nPulse oximeter functioning\nKnown allergies\nDifficult airway / aspiration risk\nRisk of blood loss > 500 mL",
     "Team introductions by name and role\nPatient name, procedure, site confirmed\nAntibiotics prophylaxis confirmed\nEssential imaging displayed\nAnticipated critical events:\n  – Surgeon: critical steps, blood loss\n  – Anaesthetist: patient-specific concerns\n  – Nursing: equipment sterility, concerns",
     "Nurse verbally confirms instrument/swab/needle count\nSpecimen labelling confirmed\nEquipment problems to be addressed\nSurgeon, anaesthetist & nurse: key concerns for recovery\nPatient destination confirmed"],
  ];

  s.addTable(checklistData, {
    x: 0.35, y: 1.75, w: 12.6, h: 4.8,
    border: { pt: 1, color: C.steelLight },
    fill: { color: C.darkSlate },
    fontSize: 11, color: C.offWhite, fontFace: "Calibri",
    align: "left", valign: "top",
    colW: [4.2, 4.2, 4.2],
  });

  s.addText("Haynes et al. (2009, NEJM): Mortality reduced from 1.5% → 0.8%; complications from 11% → 7% after checklist introduction across 8 international sites.", {
    x: 0.35, y: 6.7, w: 12.6, h: 0.4,
    fontSize: 11, color: C.amberLight, italic: true, fontFace: "Calibri",
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — CLOSED-LOOP COMMUNICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 05 · Closed-Loop Communication & SBAR");
  slideTitle(s, "Closed-Loop Communication", "The gold standard for directive communication during critical events");
  accentLine(s);
  pageNumber(s, 10, TOTAL);

  // Three steps visual
  const steps = [
    { n: "STEP 1", title: "Sender Issues Directive", body: "Name the recipient directly\nState the task clearly and specifically\nInclude dose/route/timing if medication\n\nEXAMPLE:\n'Sarah — draw up 100 mcg fentanyl IV please'", x: 0.3, col: C.steel },
    { n: "STEP 2", title: "Receiver Acknowledges", body: "Repeat back the instruction verbatim\nMakes errors detectable immediately\nConfirms understanding, not just hearing\n\nEXAMPLE:\n'100 mcg fentanyl IV — drawing up now'", x: 4.55, col: C.amber },
    { n: "STEP 3", title: "Sender Closes the Loop", body: "Receive confirmation of task completion\nActively follow up if loop is not closed\nEssential in high-noise environments\n\nEXAMPLE:\n'Fentanyl given' → 'Thank you, documented'", x: 8.8, col: C.green },
  ];

  steps.forEach(step => {
    s.addShape(pres.ShapeType.roundRect, {
      x: step.x, y: 1.75, w: 4.0, h: 5.0,
      fill: { color: C.darkSlate }, line: { color: step.col, pt: 2 }, rectRadius: 0.1,
    });
    s.addText(step.n, {
      x: step.x + 0.15, y: 1.85, w: 3.7, h: 0.4,
      fontSize: 13, bold: true, color: step.col, margin: 0, fontFace: "Calibri",
    });
    s.addText(step.title, {
      x: step.x + 0.15, y: 2.3, w: 3.7, h: 0.5,
      fontSize: 15, bold: true, color: C.white, margin: 0, fontFace: "Calibri",
    });
    s.addText(step.body, {
      x: step.x + 0.15, y: 2.85, w: 3.7, h: 3.6,
      fontSize: 12, color: C.offWhite, wrap: true, fontFace: "Calibri", margin: 4, valign: "top",
    });
  });

  // Arrows between boxes
  [4.3, 8.55].forEach(ax => {
    s.addShape(pres.ShapeType.rightArrow, {
      x: ax, y: 3.5, w: 0.3, h: 0.4,
      fill: { color: C.slate }, line: { type: "none" },
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — SBAR
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 05 · Closed-Loop Communication & SBAR");
  slideTitle(s, "SBAR — Structured Escalation Framework", "Situation · Background · Assessment · Recommendation");
  accentLine(s);
  pageNumber(s, 11, TOTAL);

  const sbar = [
    { letter: "S", word: "SITUATION", color: C.red,
      desc: "What is happening RIGHT NOW?",
      example: "\"This is Dr Smith, anaesthetics. I have a 65-year-old male in theatre 4 with sudden haemodynamic collapse — BP 60/40, HR 130, SpO2 94%.\"" },
    { letter: "B", word: "BACKGROUND", color: C.amber,
      desc: "Relevant clinical context",
      example: "\"He is 20 minutes into a laparoscopic cholecystectomy under GA. PMHx: IHD, TIVA running. No known allergies. He was haemodynamically stable until 5 minutes ago.\"" },
    { letter: "A", word: "ASSESSMENT", color: C.steelLight,
      desc: "Your clinical interpretation",
      example: "\"My differential includes anaphylaxis, major haemorrhage, tension pneumothorax, or AMI. I have stopped the volatile, given 500 mL fluid bolus and adrenaline 50 mcg.\"" },
    { letter: "R", word: "RECOMMENDATION", color: C.green,
      desc: "What do you need / suggest?",
      example: "\"I need senior surgical assistance immediately, a second anaesthetist, and activation of the major haemorrhage protocol. Can you attend now?\"" },
  ];

  sbar.forEach((item, i) => {
    const y = 1.75 + i * 1.35;
    s.addShape(pres.ShapeType.rect, {
      x: 0.3, y, w: 0.55, h: 1.2,
      fill: { color: item.color }, line: { type: "none" },
    });
    s.addText(item.letter, {
      x: 0.3, y: y + 0.3, w: 0.55, h: 0.6,
      fontSize: 28, bold: true, color: C.white, align: "center", margin: 0, fontFace: "Calibri",
    });
    s.addShape(pres.ShapeType.roundRect, {
      x: 0.95, y, w: 12.05, h: 1.2,
      fill: { color: C.darkSlate }, line: { color: item.color, pt: 1 }, rectRadius: 0.06,
    });
    s.addText(item.word + " — " + item.desc, {
      x: 1.1, y: y + 0.05, w: 11.75, h: 0.35,
      fontSize: 13, bold: true, color: item.color, margin: 0, fontFace: "Calibri",
    });
    s.addText(item.example, {
      x: 1.1, y: y + 0.42, w: 11.75, h: 0.72,
      fontSize: 11, color: C.offWhite, italic: true, wrap: true, fontFace: "Calibri", margin: 0,
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — CRM COMMUNICATION IN CRISIS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 06 · Crisis Resource Management Communication");
  slideTitle(s, "Communication During a Critical Incident", "Principles of effective leadership communication under pressure");
  accentLine(s);
  pageNumber(s, 12, TOTAL);

  bulletBox(s, [
    { bold: "Declare the emergency early and explicitly" },
    { sub: "'I am calling a cardiac arrest — please activate the team, this is not a drill'" },
    { sub: "Ambiguity about whether a situation is truly critical delays action and wastes precious seconds" },
    { bold: "Designate roles out loud" },
    { sub: "'Tom — chest compressions. Jane — draw up adrenaline. Mike — take over airway'" },
    { sub: "Role clarity reduces duplication and gaps in care" },
    { bold: "Maintain the 10-second rule" },
    { sub: "Every 10 seconds, the leader should reassess, update the team's mental model and re-prioritise tasks" },
    { sub: "'Current status: 2 minutes into CPR, no return of spontaneous circulation. Continue compressions, charging defibrillator'" },
    { bold: "'Thinking out loud' — narrated decision-making" },
    { sub: "Verbalise your diagnostic reasoning; allows team to contribute, correct and act appropriately" },
    { bold: "Managing team input during crisis" },
    { sub: "Acknowledge all suggestions, even if not actioned: 'I've heard that, noted, continuing with current plan'" },
    { sub: "Two-challenge rule: if your concern is not acknowledged twice, escalate or act" },
    { sub: "CUS words: 'I'm Concerned, I'm Uncomfortable, this is a Safety issue' — escalation trigger phrase" },
  ], { y: 1.75, h: 5.5, fontSize: 13 });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 — SPECIFIC CRISIS SCENARIOS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 06 · Crisis Resource Management Communication");
  slideTitle(s, "Communication in Specific Crisis Scenarios", "Applying CRM principles at the sharp end");
  accentLine(s);
  pageNumber(s, 13, TOTAL);

  const scenarios = [
    { t: "Cannot Intubate / Cannot Oxygenate (CICO)", b: "Declare CICO clearly — say the words\nAlert surgeon for surgical airway immediately\nDelegate BVM ventilation, THRIVE, LMA attempts\nUse DAS guidelines algorithm — verbalise each step\nCall for videolaryngoscope, bougie, surgical kit simultaneously", c: C.red },
    { t: "Anaphylaxis", b: "Say 'I think this is anaphylaxis' — diagnoses delays treatment\nDelegate adrenaline administration (closed-loop)\nAllocate roles: IV access, fluids, bronchodilators, monitoring\nCommunicate cause to surgeon — stop potential trigger\nActivate major incident response if needed", c: C.amber },
    { t: "Major Haemorrhage", b: "Activate major haemorrhage protocol explicitly\nCommunicate blood loss estimate clearly to surgeon\nDelegate: cross-match, cell salvage, warm fluids, FFP\nMaintain verbal haemodynamic updates every 2 minutes\nDocument all communications with timestamps", c: C.steelLight },
    { t: "Malignant Hyperthermia", b: "Identify and declare 'Suspected MH'\nDelegate: stop volatile, increase FGF, IV dantrolene\nCall for MH cart — closed-loop delegation essential\nCommunicate temperature trend to team\nContact MHAUS hotline / MH centre for guidance", c: C.green },
  ];

  scenarios.forEach((sc, i) => {
    const col = i < 2 ? 0 : 1;
    const row = i % 2;
    const x = col === 0 ? 0.35 : 6.85;
    const y = row === 0 ? 1.75 : 4.55;
    addCard(s, x, y, 6.25, 2.55, sc.t, sc.b, sc.c, C.darkSlate);
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 — PERIOPERATIVE HANDOVER — IMPORTANCE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 07 · Perioperative Handover");
  slideTitle(s, "Perioperative Handover — Why It Fails", "Information loss at transitions of care is a leading cause of patient harm");
  accentLine(s);
  pageNumber(s, 14, TOTAL);

  bulletBox(s, [
    { bold: "The scale of the problem" },
    { sub: "Each surgical patient undergoes an average of 9 handover events during their hospital stay" },
    { sub: "Up to 80% of serious medical errors involve miscommunication during care transitions (Joint Commission)" },
    { sub: "Intra-operative handovers (anaesthetist relief) associated with increased 30-day mortality in some studies" },
    { bold: "Types of handover in anaesthetic practice" },
    { sub: "Pre-anaesthetic: PAC to theatre anaesthetist" },
    { sub: "Intra-operative relief: anaesthetist-to-anaesthetist" },
    { sub: "Post-anaesthetic: anaesthetist to PACU / ICU nurse or intensivist" },
    { sub: "Critical care: ICU team handovers (AM/PM shift change)" },
    { bold: "Reasons handover fails" },
    { sub: "No standardised format · Information overload · Distractions and interruptions" },
    { sub: "Implicit assumptions ('they'll know that') · Status asymmetry" },
    { sub: "Time pressure · Incomplete documentation · Memory-reliance without structured prompts" },
  ], { y: 1.75, h: 5.5, fontSize: 13 });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 15 — HANDOVER FRAMEWORKS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 07 · Perioperative Handover");
  slideTitle(s, "Structured Handover Frameworks", "ISBAR · ACRM-PACU · ISOBAR — standardisation reduces omission");
  accentLine(s);
  pageNumber(s, 15, TOTAL);

  // ISBAR table
  const isbarRows = [
    [{ text: "ISBAR", options: { bold: true, color: C.white, fill: { color: C.steel } } }, { text: "Element", options: { bold: true, color: C.white, fill: { color: C.steel } } }, { text: "Anaesthetic Handover Content", options: { bold: true, color: C.white, fill: { color: C.steel } } }],
    ["I", "Identify", "Your name, role; patient name, DOB, MRN; procedure performed"],
    ["S", "Situation", "Current condition: haemodynamic status, airway, sedation level"],
    ["B", "Background", "Medical history, allergies, anaesthetic technique used, complications encountered"],
    ["A", "Assessment", "Current issues: pain score, PONV, haemostasis, fluid balance, temperature"],
    ["R", "Recommendation", "Analgesia plan, monitoring requirements, when to escalate, expected course"],
  ];

  s.addTable(isbarRows, {
    x: 0.35, y: 1.75, w: 12.6, h: 3.5,
    border: { pt: 1, color: C.steelLight },
    fill: { color: C.darkSlate },
    fontSize: 12, color: C.offWhite, fontFace: "Calibri",
    align: "left", valign: "middle",
    colW: [0.9, 2.2, 9.5],
  });

  addCard(s, 0.35, 5.5, 5.9, 1.7,
    "✅ Principles of a Good Handover",
    "• Face-to-face ('warm handover') preferred\n• Minimise interruptions — pause all non-urgent tasks\n• Read-back critical information\n• Document that handover occurred\n• Receiver must feel empowered to ask questions",
    C.green, C.darkSlate);

  addCard(s, 6.55, 5.5, 6.5, 1.7,
    "❌ Common Pitfalls to Avoid",
    "• Verbal-only handover with no documentation\n• Information delivered in surgical order, not priority order\n• Critical abnormalities buried in narrative\n• Not waiting for the receiver's full attention\n• Handing over to the wrong person",
    C.red, C.darkSlate);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 16 — BREAKING BAD NEWS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 08 · Breaking Bad News & Difficult Conversations");
  slideTitle(s, "Breaking Bad News in Anaesthetic Practice", "Post-operative complications · Awareness · Death · Unexpected findings");
  accentLine(s);
  pageNumber(s, 16, TOTAL);

  addCard(s, 0.35, 1.75, 12.6, 1.2,
    "⚠️ When anaesthetists must break bad news",
    "Intra-operative awareness (unintended consciousness) · Anaphylaxis or critical incident · Unexpected ICU admission · Patient harm from procedure · Drug error · Post-operative cognitive dysfunction · Unexpected death",
    C.amber, C.darkSlate);

  bulletBox(s, [
    { bold: "SPIKES Protocol (Baile et al., 2000) — adapted for anaesthesia" },
    { sub: "S — SETTING: Private room, sit down, no pager interruptions, family present if patient wishes" },
    { sub: "P — PERCEPTION: 'What do you already know / understand happened?'" },
    { sub: "I — INVITATION: 'Are you ready to hear more about what happened?'" },
    { sub: "K — KNOWLEDGE: Give a warning shot ('I have some difficult news...'). Be truthful, avoid jargon" },
    { sub: "E — EMOTIONS: Acknowledge and name the emotion. Silence is powerful. Do not fill pauses" },
    { sub: "S — SUMMARY & STRATEGY: Summarise what was said. Offer a follow-up meeting. Written information. Support resources" },
    { bold: "Intra-operative awareness — specific considerations" },
    { sub: "Always disclose — this is both ethically required and reduces PTSD when disclosed compassionately" },
    { sub: "Validate the patient's experience: 'I believe you completely'" },
    { sub: "Explain what happened and why, what has been done to prevent recurrence" },
    { sub: "Refer to psychologist / PTSD support services proactively" },
  ], { y: 3.1, h: 4.15, fontSize: 12 });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 17 — BARRIERS TO COMMUNICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 09 · Barriers to Effective Communication");
  slideTitle(s, "Barriers to Effective Communication in Anaesthesia", "Individual · Team · System · Environmental");
  accentLine(s);
  pageNumber(s, 17, TOTAL);

  const barriers = [
    { title: "Individual Barriers", items: ["Fatigue and cognitive overload", "High stress / task fixation", "Confirmation bias in diagnosis", "Language differences", "Poor assertiveness (junior->senior gradient)", "Emotional dysregulation"], col: C.red, x: 0.35 },
    { title: "Team Barriers", items: ["Authority gradient / hierarchy", "Lack of shared mental model", "Unclear roles and responsibilities", "Dysfunctional team dynamics", "Assumption of implicit communication", "Resistance to closed-loop practice"], col: C.amber, x: 3.6 },
    { title: "Environmental Barriers", items: ["Excessive background noise", "Physical barriers (drapes, screens)", "Multiple simultaneous demands", "Equipment alarms and distractors", "Staff changes / unfamiliar team", "Poor lighting for non-verbal cues"], col: C.steelLight, x: 6.85 },
    { title: "System Barriers", items: ["Inadequate documentation systems", "No standardised handover tools", "Time pressure from scheduling", "Insufficient simulation training", "Lack of communication safety culture", "Poor incident reporting culture"], col: C.green, x: 10.1 },
  ];

  barriers.forEach(b => {
    s.addShape(pres.ShapeType.roundRect, {
      x: b.x, y: 1.75, w: 3.0, h: 5.5,
      fill: { color: C.darkSlate }, line: { color: b.col, pt: 2 }, rectRadius: 0.1,
    });
    s.addText(b.title, {
      x: b.x + 0.1, y: 1.85, w: 2.8, h: 0.4,
      fontSize: 13, bold: true, color: b.col, fontFace: "Calibri", margin: 0,
    });
    const richItems = b.items.map((item, i) => ({
      text: item,
      options: {
        bullet: { color: b.col },
        color: C.offWhite, fontSize: 12,
        breakLine: i < b.items.length - 1,
        paraSpaceBefore: 6,
      },
    }));
    s.addText(richItems, {
      x: b.x + 0.1, y: 2.35, w: 2.8, h: 4.6,
      fontFace: "Calibri", valign: "top", margin: 4,
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 18 — HIERARCHY & PSYCHOLOGICAL SAFETY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 10 · Hierarchy, Power & Psychological Safety");
  slideTitle(s, "Psychological Safety in the Operating Theatre", "Amy Edmondson's framework applied to anaesthetic practice");
  accentLine(s);
  pageNumber(s, 18, TOTAL);

  addCard(s, 0.35, 1.75, 6.0, 2.0,
    "📖 Definition — Psychological Safety",
    "The shared belief that the team is safe for interpersonal risk-taking. Team members feel able to speak up, ask questions, report errors, and challenge plans WITHOUT fear of punishment, embarrassment or retaliation.\n(Edmondson, 1999)",
    C.steelLight, C.darkSlate);

  addCard(s, 6.65, 1.75, 6.3, 2.0,
    "🎖️ The Authority Gradient in Anaesthesia",
    "Defined as the difference in perceived authority between team members. A steep gradient (consultant >> ODP) can prevent team members raising safety concerns. Even experienced colleagues may not challenge a consultant's plan without explicit invitation.",
    C.red, C.darkSlate);

  addCard(s, 0.35, 4.0, 12.6, 1.5,
    "✅ How Consultants Can Build Psychological Safety",
    "• Explicitly invite challenge: 'Please speak up if you see something I've missed or you disagree with my plan'\n• Thank people for raising concerns, even if they were incorrect\n• Model openness by disclosing your own uncertainties and near-misses\n• Never punish or dismiss a concern — address the concern, then the communication later if needed\n• Use first names; brief the team by introducing yourself and establishing norms",
    C.green, C.darkSlate);

  addCard(s, 0.35, 5.7, 12.6, 1.5,
    "⚠️ The Two-Challenge Rule & CUS Words",
    "If a concern is expressed TWICE and not acknowledged — the person raising it is empowered to STOP the action.\n\nCUS words: 'I'm CONCERNED' → 'I'm UNCOMFORTABLE' → 'This is a SAFETY issue'\nEach escalation step signals increasing urgency and must be acknowledged.",
    C.amber, C.darkSlate);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 19 — ELECTRONIC & WRITTEN COMMUNICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 11 · Electronic & Written Communication");
  slideTitle(s, "Electronic & Written Communication in Anaesthesia", "Anaesthetic records · EPRs · Referrals · Handover documentation");
  accentLine(s);
  pageNumber(s, 19, TOTAL);

  bulletBox(s, [
    { bold: "Anaesthetic Record — Minimum Standards (RCoA)" },
    { sub: "Patient ID · date · personnel · ASA grade · procedure · anaesthetic technique" },
    { sub: "Drugs administered (dose, route, time, batch number for blood products)" },
    { sub: "Monitoring values and intraoperative events" },
    { sub: "Airway management details including grade of laryngoscopy" },
    { sub: "Fluid balance · Position · Complications · Post-op instructions" },
    { bold: "Electronic Patient Records (EPRs) — communication considerations" },
    { sub: "EPRs improve legibility but do not guarantee information transfer — critical information must be flagged prominently" },
    { sub: "Alert fields for allergies, difficult airway, implants must be actively populated" },
    { sub: "Structured alerts (e.g. 'DIFFICULT AIRWAY — plan documented in notes') reduce errors" },
    { bold: "Referral and escalation communication" },
    { sub: "SBAR structure works equally well in written escalation notes and referral letters" },
    { sub: "Include a clear 'ask' — what you need the recipient to do" },
    { bold: "Incident reporting & learning" },
    { sub: "Datix / local systems: objective language, no blame, factual timeline" },
    { sub: "Communication incident reporting is under-represented — actively encourage a reporting culture" },
  ], { y: 1.75, h: 5.5, fontSize: 13 });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 20 — COMMUNICATION IN SPECIFIC CONTEXTS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 12 · Communication in Specific Contexts");
  slideTitle(s, "Communication in Special Clinical Contexts", "Paediatrics · Obstetrics · Regional · Remote / Transfer");
  accentLine(s);
  pageNumber(s, 20, TOTAL);

  const contexts = [
    { t: "Paediatric Anaesthesia", b: "Age-appropriate language and explanation\nInvolve parents as communication allies\nInduction anxiety — 'distraction, not deception'\nObtain parent consent AND seek Gillick assent from older children\nPost-op: communicate directly with child first, then family", c: C.steelLight, x: 0.35, y: 1.75 },
    { t: "Obstetric Anaesthesia", b: "High-stakes communication under emotional stress\nLabour ward multidisciplinary team briefings\nExplain epidural / spinal in active labour — timing is critical\nEmergency CS: clear escalation triggers between midwife/obstetrician/anaesthetist\nSPIKES for maternal complications / neonatal outcomes", c: C.amber, x: 6.85, y: 1.75 },
    { t: "Regional Anaesthesia", b: "Patient must be awake-communicative during block performance\nContinuous verbal reassurance throughout\nExplain sensations expected: pressure, warmth, tingling — not pain\nPain or paraesthesia signals — must be acted on immediately\nConsent for sedation as adjunct — separate to block consent", c: C.green, x: 0.35, y: 4.55 },
    { t: "Inter-hospital Transfer & Remote Sites", b: "ATMIST handover for trauma/time-critical transfers\nA — Age, T — Time of incident, M — Mechanism, I — Injuries, S — Signs, T — Treatment\nDocument all communication with receiving team including times\nRemote sites: establish chain of command and escalation pathway before starting\nSatphone / radio communication — closed-loop essential", c: C.red, x: 6.85, y: 4.55 },
  ];

  contexts.forEach(c => addCard(s, c.x, c.y, 6.15, 2.55, c.t, c.b, c.c, C.darkSlate));
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 21 — MEASURING COMMUNICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 13 · Measuring & Improving Communication");
  slideTitle(s, "Measuring Communication Quality in Anaesthetic Practice", "Validated tools for assessment and quality improvement");
  accentLine(s);
  pageNumber(s, 21, TOTAL);

  const tools = [
    [{ text: "Tool", options: { bold: true, color: C.white, fill: { color: C.steel } } },
     { text: "Full Name", options: { bold: true, color: C.white, fill: { color: C.steel } } },
     { text: "Domain Assessed", options: { bold: true, color: C.white, fill: { color: C.steel } } },
     { text: "Setting", options: { bold: true, color: C.white, fill: { color: C.steel } } }],
    ["ANTS", "Anaesthetists' Non-Technical Skills", "Task management, team working, situation awareness, decision making", "Real theatre / simulation"],
    ["OTAS", "Observational Teamwork Assessment for Surgery", "Surgical team communication and teamwork", "Theatre observation"],
    ["CATS", "Communication & Teamwork Skills Assessment", "Handover communication quality", "ICU / PACU handovers"],
    ["Ottawa CRM Scale", "Ottawa Crisis Resource Management Global Rating Scale", "CRM behaviours during simulation scenarios", "Simulation debriefing"],
    ["MHPTS", "Mayo High-Performance Teamwork Scale", "Rapid 8-item team performance rating", "Real-time observation"],
    ["Situation Awareness Global Assessment", "SAGAT", "Situation awareness (communication dependency)", "Simulation"],
    ["Safety Attitudes Questionnaire", "SAQ", "Safety culture including communication norms (teamwork climate subscale)", "Departmental survey"],
  ];

  s.addTable(tools, {
    x: 0.35, y: 1.75, w: 12.6, h: 5.0,
    border: { pt: 1, color: C.steelLight },
    fill: { color: C.darkSlate },
    fontSize: 11, color: C.offWhite, fontFace: "Calibri",
    align: "left", valign: "middle",
    colW: [1.5, 3.5, 5.0, 2.6],
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 22 — IMPROVING COMMUNICATION — DEPARTMENT STRATEGIES
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  sectionBanner(s, "Section 13 · Measuring & Improving Communication");
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    { sub: "Introduce pre-theatre briefing standard: minimum 5-minute team brief before every list" },
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 23 — SIMULATION-BASED TRAINING
// ══════════════════════════════════════════════════════════════════════════════
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 24 — MEDICO-LEGAL DIMENSIONS
// ══════════════════════════════════════════════════════════════════════════════
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    { sub: "Anaesthetic chart is a legal document — corrections must be dated, timed, initialled" },
    { bold: "Handling complaints" },
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 25 — COMMUNICATION WITH FAMILIES
// ══════════════════════════════════════════════════════════════════════════════
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    { sub: "Structured family meetings: NURSE mnemonic — Name emotion, Understand, Respect, Support, Explore" },
    { sub: "End-of-life discussions: do not use euphemisms; 'dying' not 'not doing well'" },
    { sub: "DNACPR conversations: explain it is a medical decision, not abandonment of care" },
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    { sub: "Explain anaesthetic complications clearly: PONV, POCD, awareness — validate concerns" },
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 26 — NAP HIGHLIGHTS
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// ══════════════════════════════════════════════════════════════════════════════
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    { n: "04", t: "Structured handover frameworks (ISBAR) reduce information omission and patient harm at care transitions" },
    { n: "05", t: "Consultants are responsible for the psychological safety of their teams — authority gradient is a patient safety risk" },
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// ══ TITLE PAGE ════════════════════════════════════════════════════════════════
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// ══ TABLE OF CONTENTS ═════════════════════════════════════════════════════════
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  para("Section 01  —  Why Communication Matters in Anaesthesia", { color: STEEL }),
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  para("Section 03  —  Pre-operative Patient Communication & Informed Consent", { color: STEEL }),
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  para("Section 08  —  Breaking Bad News & Difficult Conversations", { color: STEEL }),
  para("Section 09  —  Barriers to Effective Communication", { color: STEEL }),
  para("Section 10  —  Hierarchy, Power & Psychological Safety", { color: STEEL }),
  para("Section 11  —  Electronic & Written Communication", { color: STEEL }),
  para("Section 12  —  Communication in Specific Clinical Contexts", { color: STEEL }),
  para("Section 13  —  Measuring & Improving Communication", { color: STEEL }),
  para("Section 14  —  Simulation-Based Communication Training", { color: STEEL }),
  para("Section 15  —  Medico-legal Dimensions", { color: STEEL }),
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// ══ SECTION 01 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("01", "Why Communication Matters in Anaesthesia"),
  heading2("The Scale of the Problem"),
  para("Communication is a core clinical competency — not a soft skill. It is directly linked to patient outcomes, team performance and medico-legal accountability. The evidence base for this is substantial and consistent."),
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  callout("Key Statistics", "• 70% of adverse events involve communication failure as a contributing factor (JCAHO sentinel event data)\n• Communication breakdown is the #1 root cause in anaesthetic critical incidents (AIMS database)\n• Up to 80% of serious medical errors involve miscommunication during care transitions (The Joint Commission)\n• Patients undergoing surgery experience an average of 9 handover events — each a potential failure point\n• 3x higher likelihood of adverse events when handover communication is substandard", "FFF3CD", AMBER),
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  heading3("Why Anaesthesia is Particularly High-Risk"),
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  bullet("The specialty spans theatre, ICU, pain, obstetrics, pre-assessment and remote locations"),
  bullet("Communication occurs across steep professional hierarchies (consultant → student → patient)"),
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  bullet("Critical events — though rare — require flawless team communication when they do occur"),
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// ══ SECTION 02 ════════════════════════════════════════════════════════════════
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  heading2("Anaesthetists' Non-Technical Skills (ANTS)"),
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    ["Task Management", "Explicit task assignment, verbalising priorities, time-calling, workload distribution"],
    ["Team Working", "Information exchange, shared understanding, coordination, assertiveness, supporting colleagues"],
    ["Situation Awareness", "Gathering information from team, verbalising concerns, updating shared mental model"],
    ["Decision Making", "Explaining reasoning out loud, inviting team input, confirming shared decision"],
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  callout("Core Principle", "Communication is embedded within ALL four ANTS categories — not siloed in 'team working' alone. Failures cascade: poor information exchange undermines situation awareness, which corrupts decision-making, which leads to task errors.", "EAF2FB", STEEL),
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  heading2("Crisis Resource Management (CRM)"),
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  heading3("The 8 Core ACRM Principles"),
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  bullet("Anticipate and plan — verbalise your differential and contingency plans to the team"),
  bullet("Call for help early — the single most important determinant of outcome in a crisis; do not delay"),
  bullet("Exercise leadership and followership — clear, acknowledged leadership prevents duplication and gaps"),
  bullet("Communicate clearly — closed-loop, directive communication; name + task + confirm receipt + report completion", 0, NAVY, true),
  bullet("Distribute the workload — delegate explicitly; avoid task fixation; monitor team cognitive load"),
  bullet("Mobilise all available resources — people, equipment, protocols; use everything available"),
  bullet("Use cognitive aids — CEMACH, DAS, anaphylaxis algorithms; verbalise each step"),
  spacer(),
  pageBreak()
);

// ══ SECTION 03 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("03", "Pre-operative Patient Communication & Informed Consent"),
  heading2("The Pre-operative Anaesthetic Consultation"),
  para("The pre-operative consultation is the primary opportunity to establish rapport with the patient, reduce anxiety, gather information, communicate risk, and obtain informed consent. It must be structured, patient-centred, and documented."),
  spacer(),
  heading3("Structure of an Effective Pre-operative Consultation"),
  bullet("Preparation: review PMH, drug chart, allergies, previous anaesthetic records before entering the room", 0, NAVY, true),
  bullet("Environment: quiet, private, uninterrupted — anxiety is amplified at the pre-assessment stage"),
  bullet("Opening: introduce yourself and your role; invite the patient's agenda first"),
  bullet("  'What questions or concerns do you have about your anaesthetic today?'", 1, GREY),
  bullet("Information exchange: use plain language; avoid jargon; calibrate to health literacy level"),
  bullet("Teach-back: 'Can you tell me in your own words what will happen when you go to sleep?'"),
  bullet("Written information: provide RCoA patient information leaflets to supplement verbal discussion"),
  bullet("Capacity assessment: four pillars — Understand, Retain, Weigh up, Communicate a decision (MCA 2005)"),
  bullet("Closure: summarise the plan, invite final questions, document the full discussion"),
  spacer(),
  heading2("Informed Consent — The Post-Montgomery Landscape"),
  callout("Montgomery v Lanarkshire Health Board [2015] UKSC 11", "This Supreme Court ruling shifted the consent standard from the 'reasonable doctor' (Bolam) to the 'reasonable patient' standard. A risk is material — and must be disclosed — if a reasonable patient in this patient's circumstances would want to know about it, or if this particular patient would want to know. This is patient-centred, not profession-centred.", "FFF3CD", AMBER),
  spacer(),
  heading3("Communicating Risk Effectively"),
  bullet("Use absolute frequencies: '1 in 1,000' rather than '0.1%' — patients consistently misinterpret percentages"),
  bullet("Use frequency diagrams or visual aids where possible"),
  bullet("Contextualise within familiar risks: 'Similar likelihood to a road traffic accident in a year'"),
  bullet("Personalise to the individual: comorbidities, obesity, sleep apnoea all change risk profiles"),
  bullet("Check the patient's pre-existing risk perceptions and correct misconceptions"),
  bullet("Document explicitly: what risks were discussed, how the patient responded, any concerns raised"),
  spacer(),
  heading3("High-Risk Consent Scenarios in Anaesthesia"),
  makeTable([
    ["Scenario", "Key Communication Considerations"],
    ["Paediatric consent", "Parent/guardian consent required; Gillick competence assessment for children 16+; seek child's assent in all age-appropriate cases"],
    ["Cognitive impairment / dementia", "Formal MCA capacity assessment; involve family with patient permission; best interests decision-making process"],
    ["Emergency surgery", "Limited time does not reduce duty of candour; document what was possible to discuss"],
    ["Jehovah's Witnesses", "Advanced Directive / Advance Decision must be checked; separate consent for blood products; involve haematology/legal team if needed"],
    ["Language barrier", "Qualified interpreter mandatory — NOT a family member for consent discussions; document interpreter identity"],
    ["Awake procedures (awake fibreoptic, regional)", "Consent is a separate, additional discussion from GA consent; explain expected sensations in detail"],
  ], [30, 70]),
  spacer(),
  pageBreak()
);

// ══ SECTION 04 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("04", "Intra-operative Team Communication"),
  heading2("The Theatre Team — Roles, Hierarchy and Communication Dynamics"),
  para("Theatre teams are inherently multidisciplinary. Each profession brings distinct communication norms, training and expectations. The anaesthetist occupies a unique position: responsible for the patient's unconscious state, for the patient's safety, and simultaneously a member of a complex collaborative team."),
  spacer(),
  heading3("WHO Surgical Safety Checklist — A Communication Framework"),
  para("Introduced by WHO in 2008 and mandated in the NHS from 2009, the Surgical Safety Checklist is fundamentally a structured communication tool. Haynes et al. (2009, NEJM) demonstrated mortality reduction from 1.5% to 0.8% and complication reduction from 11% to 7% across eight international sites."),
  spacer(),
  makeTable([
    ["Sign In (Before Induction)", "Time Out (Before Incision)", "Sign Out (Before Patient Leaves Theatre)"],
    [
      "Patient identity confirmed\nConsent verified\nSite marked\nAnaesthetic machine checked\nPulse oximeter functioning\nKnown allergies declared\nDifficult airway / aspiration risk identified\nRisk of blood loss >500 mL discussed",
      "Team introductions by name and role\nPatient name, procedure, site confirmed\nAntibiotic prophylaxis confirmed\nEssential imaging displayed\nAnaesthetist: patient-specific concerns\nSurgeon: critical steps, estimated blood loss\nNurse: equipment sterility, any concerns",
      "Instrument/swab/needle count verified\nSpecimen labelling confirmed\nEquipment problems to be addressed\nKey concerns for recovery discussed\nPatient destination confirmed"
    ],
  ], [33, 33, 34], DARK),
  spacer(),
  heading3("Intra-operative Communication — Best Practice"),
  bullet("Proactive updates: 'I'm about to give a vasopressor — please expect a brief rise in BP'", 0, NAVY, true),
  bullet("Explicit task sharing with closed-loop acknowledgement: 'John, please draw up 10 mg metoclopramide now'"),
  bullet("Haemodynamic and airway updates to surgeon at natural breaks — do not wait to be asked"),
  bullet("End-of-list review: ensure any intra-operative concerns are communicated to recovery team"),
  spacer(),
  pageBreak()
);

// ══ SECTION 05 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("05", "Closed-Loop Communication & SBAR"),
  heading2("Closed-Loop Communication"),
  para("Closed-loop communication is the gold standard for all directive communication during high-stakes clinical events. It transforms instructions from one-way broadcasts into verified information transfers."),
  spacer(),
  makeTable([
    ["Step", "Actor", "Action", "Example"],
    ["1 — Issue directive", "Sender (leader)", "Name the recipient directly; state the task clearly; include dose/route/timing", "'Sarah — draw up 100 mcg fentanyl IV please'"],
    ["2 — Acknowledge", "Receiver", "Repeat the instruction verbatim; confirms understanding, not just hearing", "'100 mcg fentanyl IV — drawing up now'"],
    ["3 — Close the loop", "Receiver → Sender", "Report completion; sender actively follows up if loop is not closed", "'Fentanyl 100 mcg given IV'  →  'Thank you, documented'"],
  ], [18, 18, 30, 34]),
  spacer(),
  callout("Critical Pitfall", "In high-noise environments, team members may hear without understanding, or acknowledge without acting. The loop MUST be closed — if it is not, the leader must actively follow up. Assuming the task has been done is a common source of medication and timing errors.", "FDECEA", RED),
  spacer(),
  heading2("SBAR — Structured Communication for Escalation"),
  para("SBAR (Situation, Background, Assessment, Recommendation) provides a shared mental framework for communication between clinicians across different professional roles and levels of training. It is particularly powerful during escalation calls, handovers and emergency activations."),
  spacer(),
  makeTable([
    ["Letter", "Element", "Content", "Anaesthetic Crisis Example"],
    ["S", "SITUATION", "What is happening right now?", "'This is Dr Smith, anaesthetics. I have a 65-year-old male in theatre 4 with sudden haemodynamic collapse — BP 60/40, HR 130, SpO2 94%.'"],
    ["B", "BACKGROUND", "Relevant clinical context", "'He is 20 minutes into a laparoscopic cholecystectomy under GA. PMHx: IHD. No known allergies. Stable until 5 minutes ago.'"],
    ["A", "ASSESSMENT", "Your clinical interpretation", "'My differential includes anaphylaxis, major haemorrhage, tension pneumothorax or AMI. I have stopped the volatile, given 500 mL fluid bolus and adrenaline 50 mcg.'"],
    ["R", "RECOMMENDATION", "What you need / suggest", "'I need senior surgical attendance immediately, a second anaesthetist, and activation of the major haemorrhage protocol. Can you attend now?'"],
  ], [8, 18, 28, 46]),
  spacer(),
  pageBreak()
);

// ══ SECTION 06 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("06", "Crisis Resource Management — Communication During Critical Events"),
  heading2("Communication During a Critical Incident"),
  heading3("Declaring the Emergency"),
  bullet("State the emergency explicitly — do not hint or understate: 'I am calling a cardiac arrest — this is not a drill'", 0, RED, true),
  bullet("Ambiguity delays action. Every second spent determining whether a situation is truly critical is a second of treatment lost"),
  bullet("Communicate the working diagnosis early, even if uncertain: 'This looks like anaphylaxis, treating as such'"),
  spacer(),
  heading3("Designating Roles Out Loud"),
  bullet("'Tom — chest compressions. Jane — draw up adrenaline 1 mg IV. Mike — take over airway management'"),
  bullet("Role clarity eliminates duplication and gaps — in unstructured emergencies, tasks are either done twice or not at all"),
  bullet("The leader should not perform tasks — the leader communicates, directs, and maintains the overview"),
  spacer(),
  heading3("Maintaining the Shared Mental Model"),
  bullet("Update the team's situational awareness every ~10 seconds: 'Two minutes into CPR, no ROSC, charging to 200J'"),
  bullet("'Think out loud' — narrate your diagnostic reasoning so the team can contribute, correct or act in parallel"),
  bullet("Acknowledge all team input, even if not actioned: 'I've heard that, noted, continuing with current plan'"),
  spacer(),
  heading3("Specific Crisis Communication Scenarios"),
  makeTable([
    ["Scenario", "Key Communication Actions"],
    ["CICO — Cannot Intubate Cannot Oxygenate", "Declare 'CICO' explicitly by name; alert surgeon for surgical airway immediately; delegate BVM ventilation, THRIVE, LMA attempts simultaneously; verbalise each step of the DAS guideline algorithm"],
    ["Anaphylaxis", "Say 'I think this is anaphylaxis' — the diagnosis must be stated to trigger the correct protocol; delegate adrenaline (closed-loop); communicate suspected trigger to surgeon; activate major incident response if needed"],
    ["Major Haemorrhage", "Activate MHP explicitly with those words; communicate blood loss estimate to surgeon every 2 minutes; delegate cross-match, cell salvage, warm fluids, FFP; document all communications with timestamps"],
    ["Malignant Hyperthermia", "Declare 'Suspected MH'; delegate: stop volatile, increase FGF, IV dantrolene preparation; verbalise temperature trend; contact MHAUS hotline; assign one person as documentation lead"],
    ["Local Anaesthetic Systemic Toxicity (LAST)", "Call for help immediately; verbalise LAST diagnosis; delegate intralipid preparation (closed-loop); airway management early; activate resuscitation team"],
  ], [25, 75]),
  spacer(),
  heading3("CUS Words — Escalating a Safety Concern"),
  callout("Two-Challenge Rule & CUS", "If a concern is not acknowledged after being raised TWICE — the person raising it is empowered to stop the action.\n\n'I'm CONCERNED' → 'I'm UNCOMFORTABLE' → 'This is a SAFETY issue'\n\nEach step signals increasing urgency. All team members — regardless of grade — can and must use this language. Leaders must respond to each CUS word explicitly.", "FFF3CD", AMBER),
  spacer(),
  pageBreak()
);

// ══ SECTION 07 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("07", "Perioperative Handover"),
  heading2("Why Perioperative Handover Fails"),
  para("Handover — the transfer of professional responsibility and accountability for a patient — is the most common and most hazardous communication event in anaesthetic practice. Each failure to transfer complete, accurate information is a potential patient safety event."),
  spacer(),
  heading3("Types of Handover in Anaesthetic Practice"),
  bullet("Pre-anaesthetic: PAC team / ward team to theatre anaesthetist"),
  bullet("Intra-operative relief: anaesthetist-to-anaesthetist (associated with increased 30-day mortality in some studies)"),
  bullet("Post-anaesthetic: anaesthetist to PACU nurse, PACU to ward, theatre to ICU/HDU"),
  bullet("Critical care: intensivist/anaesthetist ICU shift handovers (AM/PM)"),
  bullet("Inter-speciality: anaesthetics to surgical team, to pain team, to obstetric team"),
  spacer(),
  heading3("Reasons Handover Fails"),
  bullet("No standardised format — content is variable and relies on individual recall"),
  bullet("Information overload — not all information is equally important; critical items are buried"),
  bullet("Distractions and interruptions — theatre environment is not optimised for verbal communication"),
  bullet("Implicit assumptions — 'they'll know that' — leads to systematic omissions"),
  bullet("Status asymmetry — authority gradient prevents receivers from asking clarifying questions"),
  bullet("Time pressure — perceived urgency compresses a process that requires adequate time"),
  spacer(),
  heading2("Structured Handover Frameworks"),
  heading3("ISBAR — For Perioperative Handover"),
  makeTable([
    ["Letter", "Element", "Anaesthetic Handover Content"],
    ["I", "Identify", "Your name, role; patient full name, DOB, MRN; procedure performed; operating surgeon"],
    ["S", "Situation", "Current condition: haemodynamic status, level of consciousness, airway in situ, SpO2, pain score"],
    ["B", "Background", "PMH, allergies, anaesthetic technique used, airway grade/difficulty, complications encountered, intra-operative events"],
    ["A", "Assessment", "Current issues: pain, PONV, haemostasis, fluid balance, temperature, blood glucose"],
    ["R", "Recommendation", "Analgesia plan, monitoring requirements, when to escalate, expected post-op course, family to be updated"],
  ], [8, 18, 74]),
  spacer(),
  callout("Principles of a High-Quality Handover", "Face-to-face ('warm') handover preferred over telephone · Minimise all non-urgent interruptions during handover · Receiver must read back critical information · Document that handover occurred and to whom · Receiver must feel empowered to ask questions and challenge gaps · Critical abnormalities should be stated first, not buried at the end", "E8F8F0", GREEN),
  spacer(),
  callout("Common Pitfalls to Avoid", "Verbal-only handover with no documentation · Information delivered in surgical rather than priority order · Not waiting for the receiver's undivided attention · Handing over to the wrong grade of staff · Omitting allergy status, difficult airway history, or post-op analgesia plan", "FDECEA", RED),
  spacer(),
  pageBreak()
);

// ══ SECTION 08 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("08", "Breaking Bad News & Difficult Conversations"),
  heading2("When Anaesthetists Must Break Bad News"),
  para("Anaesthetists encounter situations requiring compassionate disclosure of unexpected or harmful events. These are not solely the domain of surgeons or intensivists. Common scenarios include:"),
  bullet("Intra-operative awareness (unintended consciousness under GA)"),
  bullet("Anaphylaxis or critical incident during anaesthesia"),
  bullet("Unexpected ICU or HDU admission post-operatively"),
  bullet("Drug error or wrong-route administration"),
  bullet("Post-operative cognitive dysfunction or prolonged emergence"),
  bullet("Unexpected intra-operative death or cardiac arrest"),
  spacer(),
  heading2("SPIKES Protocol — Adapted for Anaesthetic Practice"),
  makeTable([
    ["Step", "Name", "Practical Application"],
    ["S", "SETTING", "Private room, sit at eye level, silence pager, offer family presence if patient wishes, allow adequate time"],
    ["P", "PERCEPTION", "'What do you already understand about what happened during your operation?' Establishes baseline and corrects misconceptions"],
    ["I", "INVITATION", "'Are you ready to hear more about what happened? Would you like a family member present?' Respects patient autonomy over information"],
    ["K", "KNOWLEDGE", "Warning shot: 'I have some difficult news to share.' Then factual, jargon-free explanation. Pause frequently. Check understanding."],
    ["E", "EMOTIONS", "Acknowledge and name the emotion. 'I can see this is very distressing.' Silence is powerful — do not fill pauses. Offer tissues, water."],
    ["S", "SUMMARY & STRATEGY", "Summarise key points. Offer written summary. Plan follow-up. Refer to psychologist, chaplaincy, PALS. Document discussion fully."],
  ], [8, 18, 74]),
  spacer(),
  heading3("Intra-operative Awareness — Specific Communication Requirements"),
  callout("Duty to Disclose", "Disclosure of intra-operative awareness is both ethically required and clinically beneficial. When disclosed compassionately and promptly, the incidence of PTSD is significantly reduced. Validate the patient's experience explicitly: 'I believe you completely. What you experienced was real.' Never minimise or dismiss their account.", "FFF3CD", AMBER),
  spacer(),
  bullet("Explain clearly what happened, why it may have occurred, and what will be done to prevent recurrence"),
  bullet("Provide written information about awareness (NAP5 patient resources)"),
  bullet("Refer proactively to clinical psychology or PTSD support services"),
  bullet("Document the conversation in detail: date, time, who was present, what was said, patient response"),
  bullet("File a critical incident report and discuss at anaesthetic governance meeting"),
  spacer(),
  pageBreak()
);

// ══ SECTION 09 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("09", "Barriers to Effective Communication"),
  heading2("A Taxonomy of Communication Barriers in Anaesthesia"),
  makeTable([
    ["Category", "Specific Barriers"],
    ["Individual", "Fatigue and cognitive overload · High stress and task fixation · Confirmation bias · Language differences · Poor assertiveness · Emotional dysregulation · Excessive self-confidence or excessive self-doubt"],
    ["Team", "Authority gradient / steep hierarchy · Lack of shared mental model · Unclear roles and responsibilities · Dysfunctional interpersonal dynamics · Reliance on implicit communication · Resistance to closed-loop practice"],
    ["Environmental", "Excessive background noise · Physical barriers (drapes, screens, distance) · Multiple simultaneous competing demands · Equipment alarms as distraction · Unfamiliar team members · Poor lighting limiting non-verbal cues"],
    ["Systemic", "No standardised handover tools · Inadequate documentation systems · Time pressure from theatre scheduling · Insufficient simulation training investment · Lack of a positive safety culture · Poor incident reporting infrastructure"],
  ], [20, 80]),
  spacer(),
  callout("The Compounding Effect", "These barriers rarely act in isolation. Fatigue (individual) + unfamiliar team (environmental) + no handover standard (systemic) + steep hierarchy (team) = a situation where critical information reliably fails to transfer, and no individual feels empowered to correct it. Systems thinking is required — not blame.", "EAF2FB", STEEL),
  spacer(),
  pageBreak()
);

// ══ SECTION 10 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("10", "Hierarchy, Power & Psychological Safety"),
  heading2("The Authority Gradient in Anaesthetic Practice"),
  para("The authority gradient — the difference in perceived authority between team members — is one of the most potent and underappreciated determinants of communication quality in the operating theatre. A steep gradient (Consultant >> SHO >> ODP >> student) systematically suppresses safety-critical communication from lower to higher ranks."),
  spacer(),
  callout("Psychological Safety — Definition", "The shared belief that the team is safe for interpersonal risk-taking. Team members feel able to speak up, ask questions, report errors, and challenge plans WITHOUT fear of punishment, embarrassment or retaliation. (Edmondson, 1999)\n\nTeams with high psychological safety have lower error rates, faster error recovery, and higher learning rates.", "EAF2FB", STEEL),
  spacer(),
  heading3("How Consultants Can Actively Build Psychological Safety"),
  bullet("Explicitly invite challenge before the case: 'Please speak up if you see something I've missed or disagree with my plan'", 0, NAVY, true),
  bullet("Thank people for raising concerns — regardless of whether they were correct"),
  bullet("Model openness by disclosing your own uncertainties, near-misses and learning points"),
  bullet("Never visibly dismiss or punish a concern — address the safety issue first, communication approach separately"),
  bullet("Use first names throughout the list; ensure all team members have been introduced"),
  bullet("Brief the entire team, not just the surgeon — ODPs, scrub nurses and students need inclusion"),
  bullet("After an error: focus on the system, not the individual; create a psychologically safe debrief"),
  spacer(),
  heading3("The Two-Challenge Rule and CUS Words"),
  para("These are explicit, organisation-sanctioned communication tools for overcoming authority gradient. Their power lies in normalising the language of escalation so that no individual feels they are 'going rogue' by using them."),
  bullet("CUS Step 1 — 'I'm CONCERNED': signals a concern deserving acknowledgement"),
  bullet("CUS Step 2 — 'I'm UNCOMFORTABLE': signals the concern is urgent and the plan should pause"),
  bullet("CUS Step 3 — 'This is a SAFETY issue': signals an immediate stop is required"),
  bullet("Two-Challenge Rule: if a concern is not acknowledged after being raised TWICE, the person is empowered — and obligated — to halt the action"),
  spacer(),
  pageBreak()
);

// ══ SECTION 11 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("11", "Electronic & Written Communication"),
  heading2("The Anaesthetic Record as a Communication Tool"),
  para("The anaesthetic chart is simultaneously a clinical record, a medico-legal document, and a communication instrument. It must be legible, complete, contemporaneous and structured such that a clinician unfamiliar with the patient can reconstruct the intra-operative course in full."),
  spacer(),
  heading3("RCoA Minimum Standards for the Anaesthetic Record"),
  bullet("Patient identification, date, operating theatre number, personnel names and grades"),
  bullet("ASA physical status, procedure, anaesthetic technique"),
  bullet("All drugs administered: generic name, dose, route, time — batch number for blood products"),
  bullet("Monitoring values: baseline and at regular intervals; all alarms documented"),
  bullet("Airway management details: device used, grade of laryngoscopy, number of attempts"),
  bullet("Position, warming, padding, eye care"),
  bullet("Fluid balance: input and estimated losses"),
  bullet("Intra-operative events and complications"),
  bullet("Post-operative instructions: analgesia plan, monitoring, when to escalate, destination"),
  spacer(),
  heading2("Electronic Patient Records — Opportunities and Pitfalls"),
  bullet("EPRs improve legibility but do not guarantee information transfer", 0, NAVY, true),
  bullet("Critical information (difficult airway, allergy, implants) must be flagged in structured alert fields — not buried in free text"),
  bullet("Structured alerts — 'DIFFICULT AIRWAY — Video laryngoscopy used, plan documented in notes' — reduce repeat failed intubations"),
  bullet("The absence of a documented allergy does NOT mean no allergy — this must be verified verbally at every encounter"),
  spacer(),
  heading3("Incident Reporting — Communication of Learning"),
  bullet("Datix / AIMS / local systems: objective language, factual timeline, no personal blame"),
  bullet("Communication incidents are consistently under-reported — actively normalise reporting these events"),
  bullet("Closed-loop organisational learning: every report should generate a feedback loop to the reporter"),
  spacer(),
  pageBreak()
);

// ══ SECTION 12 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("12", "Communication in Specific Clinical Contexts"),
  heading2("Paediatric Anaesthesia"),
  bullet("Age-appropriate language and explanation — use visual aids and play for young children"),
  bullet("Involve parents as communication allies — they can help translate your message to the child"),
  bullet("Induction anxiety management: distraction and honesty are more effective than deception"),
  bullet("Consent from parent/guardian; seek Gillick assent from children 12+ using developmentally appropriate language"),
  bullet("Post-operatively: speak directly to the child first, then to the family"),
  spacer(),
  heading2("Obstetric Anaesthesia"),
  bullet("Labour ward multidisciplinary briefings: midwife-obstetrician-anaesthetist triad is essential", 0, NAVY, true),
  bullet("Epidural/spinal consent in active labour: timing is critical — initiate discussion early, not at crisis point"),
  bullet("Category 1 CS: clear, pre-agreed escalation language between all team members"),
  bullet("Communication of neonatal outcome to the mother — SPIKES applies here; coordinate with obstetric and neonatal team"),
  bullet("MBRRACE themes: authority gradient between midwife and anaesthetist repeatedly delays critical intervention"),
  spacer(),
  heading2("Regional Anaesthesia"),
  bullet("The awake patient requires continuous verbal reassurance throughout block performance"),
  bullet("Explain expected sensations clearly: pressure, warmth, tingling — and specifically that pain means something is wrong"),
  bullet("Pain or paraesthesia during needle placement: stop immediately, verbalise, reassess position"),
  bullet("Consent for sedation as adjunct is a separate discussion from the block consent itself"),
  spacer(),
  heading2("Inter-hospital Transfer and Remote Sites"),
  heading3("ATMIST — Structured Transfer Communication"),
  makeTable([
    ["Letter", "Element", "Content"],
    ["A", "Age", "Age of patient and relevant demographic"],
    ["T", "Time", "Time of incident / deterioration / decision to transfer"],
    ["M", "Mechanism", "Mechanism of injury or cause of admission"],
    ["I", "Injuries / Illness", "Confirmed and suspected injuries or clinical problems"],
    ["S", "Signs", "Vital signs including GCS, airway status, haemodynamic state"],
    ["T", "Treatment", "Treatment given pre-hospital and in transit; drugs and doses"],
  ], [8, 18, 74]),
  spacer(),
  bullet("Establish chain of command and escalation pathway before departing — not mid-transfer"),
  bullet("Document all communications with receiving team including times and names"),
  bullet("Remote sites: identify the limitations of the environment to the team before starting"),
  spacer(),
  pageBreak()
);

// ══ SECTION 13 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("13", "Measuring & Improving Communication"),
  heading2("Validated Assessment Tools"),
  makeTable([
    ["Tool", "Full Name", "Domain", "Setting"],
    ["ANTS", "Anaesthetists' Non-Technical Skills", "All NTS including communication", "Theatre / Simulation"],
    ["OTAS", "Observational Teamwork Assessment for Surgery", "Surgical team communication", "Theatre observation"],
    ["CATS", "Communication & Teamwork Skills Assessment", "Handover quality", "ICU / PACU"],
    ["Ottawa CRM", "Ottawa CRM Global Rating Scale", "CRM behaviours", "Simulation debriefing"],
    ["MHPTS", "Mayo High-Performance Teamwork Scale", "Rapid 8-item team rating", "Real-time observation"],
    ["SAQ", "Safety Attitudes Questionnaire", "Teamwork climate / safety culture", "Departmental survey"],
    ["SAGAT", "Situation Awareness Global Assessment", "Situation awareness (communication-dependent)", "Simulation"],
  ], [12, 28, 35, 25]),
  spacer(),
  heading2("Departmental Strategies for Improvement"),
  heading3("Standardise Processes"),
  bullet("Implement department-wide ISBAR handover template — printed aide-memoires in all anaesthetic rooms and PACU", 0, NAVY, true),
  bullet("Audit WHO Surgical Safety Checklist compliance for QUALITY, not just completion rates"),
  bullet("Introduce a standardised pre-list team brief of minimum 5 minutes for every operating list"),
  spacer(),
  heading3("Build a Reporting and Learning Culture"),
  bullet("Actively encourage Datix reporting of communication incidents — no-blame culture must be demonstrated, not just stated"),
  bullet("Present anonymised communication cases at monthly M&M and audit meetings"),
  bullet("Share learning from national databases: NAP4, NAP5, NAP6, NHS England Learning from Deaths"),
  spacer(),
  heading3("Faculty Development"),
  bullet("Train consultants as communication coaches — not just technical supervisors"),
  bullet("Normalise communication language: make 'closed-loop', 'SBAR', 'CUS words' terms every theatre team member knows"),
  bullet("360-degree feedback specifically addressing communication behaviours in annual appraisal"),
  spacer(),
  pageBreak()
);

// ══ SECTION 14 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("14", "Simulation-Based Communication Training"),
  heading2("Why Simulation is the Preferred Method for Communication Training"),
  bullet("Provides a safe environment to practise rare, high-stakes scenarios without patient risk"),
  bullet("Allows behavioural observation using validated tools (ANTS, Ottawa CRM scale)"),
  bullet("Structured debriefing enables deep, reflective learning about communication"),
  bullet("Addresses both individual communication and team-level communication simultaneously"),
  bullet("Exposure to uncommon crises maintains competence that real-life practice alone cannot provide"),
  spacer(),
  heading2("Types of Simulation in Anaesthetic Communication Training"),
  makeTable([
    ["Type", "Description", "Best For"],
    ["Full-scale mannequin simulation (ACRM)", "High-fidelity simulator in dedicated simulation centre", "CRM communication, crisis management, CICO, anaphylaxis"],
    ["In-situ simulation", "Scenarios run in real theatre environment with real team", "Handover failures, checklist compliance, system latent errors"],
    ["Standardised patient", "Actor portrays patient in scripted clinical encounter", "Consent, breaking bad news, SPIKES training, pre-op consultation"],
    ["Tabletop / scenario workshops", "Facilitated group discussion of case vignettes", "SBAR practice, decision-making communication, hierarchy issues"],
    ["Translational simulation", "Simulation designed to identify and fix real system problems", "Department-specific communication failures (Rao & Dennis, 2026)"],
  ], [20, 45, 35]),
  spacer(),
  heading2("Principles of Effective Debriefing"),
  callout("The Debriefing is the Learning", "Research consistently shows that the quality of the debrief determines whether simulation training improves performance. A poor debrief can actually reinforce bad habits. Debriefing must be conducted by a trained facilitator using a structured approach.", "EAF2FB", STEEL),
  spacer(),
  bullet("Conduct IMMEDIATELY post-scenario — within 30 minutes while recall is fresh", 0, NAVY, true),
  bullet("Establish psychological safety before beginning: 'This is a safe space; we're here to learn, not to judge'"),
  bullet("Use the advocacy-inquiry model: 'I noticed X — can you help me understand what was going through your mind at that point?'"),
  bullet("Focus on behaviours and systems, NOT personal attributes"),
  bullet("Plus-Delta structure (what worked / what to change) or Gather-Analyse-Summarise framework"),
  bullet("Every participant must leave with at least one specific, actionable learning point"),
  bullet("Evidence: simulation gains in communication are sustained only when debriefing is high-quality (Fletcher et al.; Patten et al. 2026)"),
  spacer(),
  pageBreak()
);

// ══ SECTION 15 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("15", "Medico-legal Dimensions of Anaesthetic Communication"),
  heading2("Key Medico-legal Frameworks"),
  heading3("Duty of Candour — Regulation 20, Health & Social Care Act 2008"),
  callout("Statutory Duty of Candour", "NHS providers and registered professionals have a statutory duty to be open and honest with patients when something goes wrong that causes harm or distress. This requires:\n• Notifying the patient (or family) as soon as reasonably practicable\n• Providing a truthful account of what happened\n• Offering a sincere apology\n• Providing a written account and information about support available\n\nFailure to comply is a regulatory offence. The GMC's Good Medical Practice framework aligns — a doctor must be honest and open when things go wrong.", "FFF3CD", AMBER),
  spacer(),
  heading3("Montgomery v Lanarkshire [2015] UKSC 11 — Consent Standard"),
  bullet("Moved the standard from 'reasonable doctor' (Bolam) to 'reasonable patient'"),
  bullet("A risk is material if a reasonable patient WOULD WANT TO KNOW, regardless of how small the probability"),
  bullet("The standard is specific to THIS patient — their values, anxieties, circumstances and lifestyle must inform the discussion"),
  bullet("Practical implication: document not just what risks were mentioned, but how the patient responded to each"),
  spacer(),
  heading3("Documentation as Communication — The Legal Dimension"),
  callout("If It Isn't Written, It Didn't Happen", "Courts apply this principle rigorously. A contemporaneous, legible and complete anaesthetic record is the single strongest defence against a clinical negligence claim. Corrections must be dated, timed and initialled — never use correction fluid. Electronic records are subject to audit trail scrutiny.", "FDECEA", RED),
  spacer(),
  heading3("Handling Patient Complaints"),
  bullet("Acknowledge promptly — delay amplifies distress and increases likelihood of formal complaint escalation"),
  bullet("Apologise for the distress caused — this is NOT an admission of liability"),
  bullet("Investigate thoroughly before responding with a substantive answer"),
  bullet("Communicate findings in plain, jargon-free language"),
  bullet("Evidence: early, open, honest communication following an adverse event reduces litigation rates significantly"),
  spacer(),
  heading2("Lessons from National Audit Projects"),
  makeTable([
    ["NAP", "Topic", "Communication Failure Identified"],
    ["NAP4 (2011)", "Major Airway Complications", "Failure to document difficult airway; failure to verbally communicate at handover — patients re-exposed to failed intubation in subsequent anaesthetics"],
    ["NAP5 (2014)", "Awareness under GA", "TIVA equipment unfamiliarity not disclosed; awareness history not shared at transfer; disclosure to patients after awareness events delayed or absent"],
    ["NAP6 (2018)", "Perioperative Anaphylaxis", "Incomplete allergy history communication; failure to update records with new anaphylaxis events; poor communication between allergy clinics and anaesthetic teams"],
    ["MBRRACE / NCEPOD", "Maternal Critical Illness", "Escalation failures between midwives, obstetricians and anaesthetists; authority gradient prevented early anaesthetic involvement in deteriorating patients"],
  ], [12, 22, 66]),
  spacer(),
  callout("Recurring NAP Theme", "Information not communicated · Information not documented · Information not escalated · Information not heard. The pattern is consistent across every national audit. Communication failures are not random — they are systematic and predictable, and they can be designed out of systems.", "FFF3CD", AMBER),
  spacer(),
  pageBreak()
);

// ══ SECTION 16 ════════════════════════════════════════════════════════════════
children.push(
  sectionHeader("16", "Summary & Key Takeaways"),
  heading2("Key Takeaways for Consultant Anaesthetists"),
  spacer(),
  makeTable([
    ["#", "Key Takeaway"],
    ["01", "Communication is a clinical skill — it must be taught, practised, measured and improved like any technical skill. Describing it as a 'soft skill' systematically undervalues and under-resources it."],
    ["02", "Closed-loop communication and SBAR are the minimum standards for high-stakes clinical exchanges. These are not optional enhancements — they are the baseline expectation."],
    ["03", "The WHO Surgical Safety Checklist is a communication tool. Compliance must be audited for quality (genuine engagement) not just completion (a signature on a form)."],
    ["04", "Structured handover frameworks (ISBAR) reduce information omission and patient harm at care transitions. Every department should have a mandated, standard format."],
    ["05", "Consultants are responsible for the psychological safety of their teams. A steep authority gradient is a patient safety risk — it is the consultant's professional obligation to flatten it deliberately."],
    ["06", "Montgomery changed consent forever. Material risk communication must be patient-centred, personalised and thoroughly documented. The Bolam standard for consent is gone."],
    ["07", "Simulation with high-quality debriefing is the most effective method for developing CRM communication skills. Investment in simulation faculty development pays dividends in patient safety."],
    ["08", "The NAPs repeatedly show communication failures drive anaesthetic harm. Learning from them is only valuable if it is translated into departmental action — not just conference presentations."],
  ], [8, 92]),
  spacer(),
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