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‘My Mental Toughness Manifesto’ Part 3: PERFORM

9 May, 17 | by rlloyd

‘Practice’ is about building a skillset, and fostering a way of life (via ‘immersion’) that serves to strengthen perception of one’s available resources when crunch time arrives.

However, reality dictates that certain scenarios are impossible to prepare for, particularly in the emergency medicine arena. The more chaotic the workplace, the higher the frequency of unavoidable threat appraisals.

Therefore, it is crucial to utilise strategies which stabilise one’s level of emotional arousal in the heat of battle. Namely tactical breathing and cognitive reframing.

Tactical Breathing

“Feel breath filling every cell of your body. This is our ritual. We master our breath, we master our mind. Pulling the trigger will become an unconscious effort. You will be aware of it, but not directing it. And as you exhale, find your natural respiratory pause and the space between heart-beats.”

American Sniper

In a high stakes game, where your next move (performance) has implications for the survival of another human being, it is a guarantee that your sympathetic nervous system will be working overtime. We know, of course, that this can work in our favour if challenged (perceived resources > demands); indeed, we’ll feel ‘pumped’ and ‘ready for action’. On the other hand, this heightened physiological arousal can be the architect of a catastrophic blunder if threatened (i.e. demands > resources; see MMTM Part 1 for a full explanation).

The only component of the autonomic nervous system that we can override and take conscious control over is our breathing [1, 2].

Deliberately slowing respiratory rate in a moment of crisis has the effect of preventing further escalation of other features of the sympathetic surge, such as tachycardia and hypertension. This feeling of control over our physiological arousal induces a prevailing sense of clarity and calm. It serves to psychologically detach the conscious self from the stressful moment, allowing an imaginary reset button to be pressed with subsequent restoration of mental bandwidth. Visual and auditory perceptions widen as the mind is released from the paralysing effect of the cortisol dump. Professional presence in the moment is re-established.

square breathing

‘Tactical breathing’ (or ‘square breathing’) describes the four-second method pioneered by Lt. Col. Dave Grossman, of On Combat fame [3]. One must breathe in for four seconds, hold for four, exhale for four and then hold again for four, on repeat until the desired effect is achieved. Whilst this provides the stressed individual with a mental model to follow, it is not essential to adhere rigidly to the timings. The crucial task is committing to a conscious slowing and deepening of one’s breathing cycle.

This idea is nothing new or revolutionary. Breathing techniques have been utilised by elite soldiers, martial artists, professional athletes, and a host of other world-beaters for generations [4]. Underestimate this tool at your peril.

Cognitive Reframing

A salient feature of the threat mindset is a thinking pattern polluted with self-doubt and persecution.

‘I can’t do this’ 

‘I don’t know what to do’ 

‘My mind is blank and my patient is dying’

Naturally, this has a devastating effect on performance. If you are telling yourself that you’re not up to the job, it is highly unlikely that you will prove yourself wrong.

Pressing ‘control/alt/delete’ on these thoughts, and inserting useful content, is therefore critical. This process is called cognitive reframing, and it can be achieved via positive self-talk and an ‘incrementalsteps’ approach.

Positive self-talk

This is the process of forcing one’s internal dialogue to suggest something positive. It can jolt the mind out of a persecutory spiral, if sufficient commitment/buy-in is present [5, 6].

It can be generally motivational:

You have trained well for this’

You’ve been in this position before and succeeded’ 

‘Relax and focus’

Or be used as a method for directing cognitive resources to something specific:

Slow is smooth, smooth is fast’ 

You have plenty of time, just bring the epiglottis into view’ 

Positive self-talk synergises well with tactical breathing, providing, in effect, a two-pronged intervention on physiological and cognitive over-arousal.

An ‘incremental-steps’ approach

During a crisis or particularly demanding scenario, it is always a bad idea to look at the big picture.

Break down the required process into its component parts, and focus only on your first step. Upon completion of that step, allow yourself to contemplate the next, and so on. This will modify your perception of the situational demands by reframing the scenario into a series of manageable challenges instead of one giant threat, and in doing so, hold off any detrimental physiology [7].

For example, if confronted with an unconscious head injury patient who is obstructing his airway and gargling blood, do not allow yourself to contemplate the overall objective (i.e. getting the patient safely anaesthetised and intubated). First focus solely on applying high-flow oxygen, appropriate monitoring, and allocating team roles. Next, focus on achieving intravenous access, followed by readying the airway equipment and drugs, then instrumenting the airway, thereafter ‘epiglottoscopy’, and so on. A state of panic is warded off by a refusal to allow the mind to wander too far forwards.

If you avoid looking at the mountain peak, and focus exclusively on the first obstacle lying in front of you, you will arrive at the summit in no time.

Use positive self-talk to encourage and guide you through each incremental step.

Summary

  • Threat appraisals are an unfortunate inevitability for all acute care clinicians.
  • Taking conscious control over your respiratory cycle grants you the ‘keys’ to the rest of your autonomic physiology.
  • Positive self-talk intervenes on persecutory thought pollution, and can redirect cognitive resources to specific tasks. It can synergise with tactical breathing as a method for ‘resetting’ in a moment of high stress.
  • An incremental-steps approach converts a significant threat into a series of manageable challenges.

In the fourth and final instalment of My Mental Toughness Manifesto, I’ll be discussing a healthy and progressive methodology for PROCESSING a highly stressful clinical encounter after the event.

I’ll leave you with NAVY Seal Commander Jocko Willink’s take on cognitive reframing:

References

  1. Mike Lauria. Enhancing Human Performance in Resuscitation Part 3 – Performance-Enhancing Psychological Skills. EMCrit Blog. Published on November 22, 2015. Accessed on May 5th 2017. Available at [https://emcrit.org/blogpost/performance-enhancing-psychological-skills/].
  2. Seppala, E.M., et al., Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study. J Trauma Stress, 2014. 27(4): p. 397-405.
  3. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.
  4. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  5. Scott Weingart. Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset. EMCrit Blog. Published on July 11, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/podcasts/chris-hicks-fog-of-war/].
  6. Tod, D., J. Hardy, and E. Oliver, Effects of self-talk: a systematic review. J Sport Exerc Psychol, 2011. 33(5): p. 666-87.
  7. Rob Orman, Rich Levitan, ERCast – Psychology of the Difficult Airway, 2014

Primary Survey April 2017.

18 Apr, 17 | by scarley

This month’s primary Survey is written by Mary Dawood. Don’t forget to visit the journal site to see more and keep in touch with us on Social Media.

Also, don’t forget to listen and subscribe to our podcast to keep you up to date on the journal and topics in emergency medicine.

Organ Donation in the ED

Possibly one of the most sensitive and daunting conversations that takes place in the ED is about organ donation. By virtue of circumstances this conversation usually occurs subsequent to breaking news of death or imminent death. Broaching the subject of organ donation can seem ill timed, insensitive and is difficult for even the most skilled clinicians. Even so, organ donation is a core competency in emergency medicine as is the management of patients in the final stages of life, furthermore we have a duty as healthcare professionals to explore this potential at the end of life. In the UK in 2015–16 a record number of organs were donated and transplanted but the consent rate is still one of the lowest in Europe. At the end of 2015 there were nearly 7000 people waiting for a transplant, 429 died while waiting and a further 807 were removed from the list most likely due to deteriorating health. Despite ongoing teaching of emergency staff and expert support from specialist nurses, opportunities for organ donation can still be lost in the urgency and fast pace of the ED as well as the perceived difficulties of managing the logistics of donation before death (DBD) or donation after circulatory death (DCD). Outcomes from DBD are better but an ongoing shortage of organs is seeing the reintroduction of a long abandoned practice of (DCD). This month’s issue includes a very informative paper by Gardiner and colleagues along with a commentary by Bernard Foex about organ donation. Gardiners paper describes current transplantation practice in the UK, associated ethical and legal issues, the classification of deceased donors and future developments promising greater numbers of organs. Foex’s commentary discusses withdrawal of life sustaining therapy and the case for delay.

Both these papers are a ‘must read’ for ED clinicians everywhere to remind us that the potential to change lives for better is enormous and the urgency for organ donation is greater than ever as we live longer.

Saving money

Containing the ever increasing costs of healthcare is both a challenge and a necessity in all health economies. We are constantly entreated by our ‘money masters’ to find not only more cost effective ways of delivering care but cheaper consumables. In the minds of many clinicians cheaper consumables often equate to poorer quality so it was very interesting to read of a study by Riguzzi et al from San Francisco comparing cost of commercially produced ultrasound gel which is relatively expensive with an alternative corn-starched based gel. They found that the corn starched gel which cost <10 cents per bottle produced images of similar quality to those using commercial gel which costs about $5 dollars. Given that point of care ultrasound is increasingly used in low resource settings, over time, this may represent a tidy sum that could be used elsewhere. Think about this the next time you liberally squirt expensive ultrasound gel!.

Sepsis again

Lifesaving treatment for sepsis is relatively straightforward–so many more lives should be saved every year if treatment is started in a timely way. It is therefore an ongoing concern that so many people still die from sepsis every year. The difficulty is spotting this complex condition as soon as a patient presents so we need to ask whether our triage systems are sufficiently sophisticated to support early recognition. Graff and colleagues in Germany undertook an evaluation of the Manchester triage system (MTS) to assess its effectiveness in identifying septic patients. They found the MTS to have some weakness with respect to priority in patients with sepsis and that discriminators for identifying systemic infection are insufficiently considered. In view of the fact that MTS and similar versions are so widely used it is well worth reading this paper to revisit our triage systems and how we can improve detection of sepsis at triage.

Weighing patients: a guestimate?

Some EDs are fortunate to have high specification trolleys that have built in scales for weighing patients. Most of us probably don’t work with such sophisticated facilities so we resort to roughly estimating a patient’s weight in emergency situations. This is a concern when using time critical drugs that require precise dosing according to weight. I was curious then to read of a study in this issue by Cattermole and colleagues in the UK that aimed to develop and validate an accurate method for estimating weight in all age groups using mid arm circumference.(MAC) They derived a simplified method of MAC based weight estimation from a linear regression equation: weight in kg=4xMAC (in cm)−50. They found that this formula is at least as precise in adults and adolescents as commonly used paediatric weight estimation tools are in children. The authors advise that a gender specific model would improve precision but this would require a tape or smartphone. This study is well worth a read as a more accurate way of estimating weight is to be welcomed especially as rising obesity levels will call for more consistent documentation of weight and precise dosing.

Adaptive design clinical trials in the ED?

Conducting and sustaining clinical trials in emergency settings can be difficult for a variety of reasons. One reason may relate to the fixed nature of the designs that are traditionally used in ED trials, where conduct and analysis are outlined at the outset and are not examined until the trial is finished. This fixed design may in many instances take too long and be costly both to patients and staff. It may be time to consider alternative way of conducting clinical trials in the ED that may be more effective and conducive to the ED setting. In this issue, Flight et al hypothetised that the majority of published emergency medicine trials have the potential to use a simple adaptive trial design where planned interim analysis is factored in to determine whether studies should be stopped or modified before recruitment is complete. Their study reviewed clinical trials published in three emergency medicine journals between January 2003 and December 2013. They found that out of 188 trials, only 19 were considered to have used an adaptive trial design. A total of 154/165 trials that were fixed in design had the potential to use an adaptive design. For those of us grappling with the challenges of clinical trials in the ED, this approach is worthy of consideration.

View Abstract

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Mary Dawood

  1. Emergency Department, Imperial College NHS Trust, London, UK
  1. Correspondence to Mary Dawood; Mary.dawood@imperial.nhs.uk

‘Why tomorrow’s patient needs a digital NHS’

6 Apr, 17 | by rlloyd

On February 22, the EMJ blog team were well represented at . This was the one-year ‘summit’ of DigitalHealth.London, an organisation (funded in large part by NHS England) designed to accelerate the uptake of digital technology in the NHS. It was part-conference, part-showcase of some potentially game-changing innovations/innovators that are starting to gain traction in global healthcare. The event was hosted by the Royal College of GPs, and it brought together NHS leaders, senior clinicians and digital entrepreneurs. I had the great honour of compèring proceedings.

The event sizzled with excitement and ambition. Conference delegates were talking about the future of the NHS in positive, expansive terms with an up-beat chirpiness that starkly contrasts the doom-and-gloom-ridden water cooler discussions currently reigning supreme across UK hospitals. The air of possibility and optimism was utterly infectious. I had a great time.

I am a now a fully-fledged digital health believer, and adoption of new technologies discussed at the event can’t come soon enough in my opinion. Interventional virtual reality? Artificial intelligence-augmented clinical decision-making? Healthcare provision to every human being on Earth via smartphones? Yes please.

I met some great people, including the inspirational Molly Watt (one of the most accomplished public speakers I’ve heard; if you haven’t heard her story, check out her website – phenomenal stuff), director of digital experience at NHS England Juliet Bauer, and the amazing Dr. Keith Grimes – a GP from Eastbourne and digital health evangelist, whose work I have admired for a while now. He gave a typically superb talk on the application of virtual reality in medicine, and has since written an insightful blog post reflecting on the artificial intelligence panel discussion. Watch this space for a future collaboration between Keith and the EMJ blog team.

DigitalHealth.London have put together a neat full write-up, and produced a couple of beautifully shot videos of the summit, which I happen to feature in! Here they are:

Needless to say, you can count on some future EMJ blog posts exploring digital transformation in healthcare!

Thank you DigitalHealth.London (in particular James Somauroo, Yinka Makinde, Rebekah Tailor, and Hannah Harniess) for inviting me to be involved in your fantastic event.

It’s a great time to be a doctor.

Rob
@PonderingEM

‘My Mental Toughness Manifesto’ Part 2: PRACTICE

15 Mar, 17 | by rlloyd

Screen Shot 2017-03-06 at 15.55.21

In MMTM Part 1, two-step cognitive appraisals were explained. This process dictates whether one enters a challenged or threatened mindset in the event where an immediate performance is required under acute stress.

Feeling challenged, of course, is one of the two chief components of a mentally tough individual.

“I am 100% committed”

“I feel challenged”

In this post, we will explore principles which must be incorporated in one’s ‘practice‘ (i.e. training) regime, to increase a sense of confidence in one’s skillset. The confident individual will always be more likely to appraise a scenario as challenging as opposed to threatening.

Paradigm shift alert: When practicing, specific skill development must be prioritised over knowledge-base widening. This, of course, sharply contrasts with the traditional approach to medical training. New theoretical concepts seem less abstract and will always be absorbed more rapidly when they fit into the mental scaffolding built by focusing on skill development.

In an ideal world, all clinicians, across the spectrum of specific role and geographic location, would get regular high-fidelity simulation training sessions, supervised by master educators. Of course, this isn’t feasible in even the richest healthcare systems; and the reality is that all types of supervised training (other than weekly death-by-PowerPoint didactic teaching) become increasingly rare the more senior you become.

Therefore, one must take ownership over one’s own practice, and be relentless in the pursuit of ultimate confidence in one’s skillset. This will be achieved through immersiondeliberate practice, and visualisation.

Immersion

“Discipline equals freedom”

Jocko Willink, Navy SEAL Commander

My definition of professional ‘immersion’ is regular engagement with one’s craft outside of working hours. The abundance of free online medical education (FOAMed) resources makes this process exceptionally easy and enjoyable. With availability/access to excellent content no longer an issue (unlike the olden days where you had to sift through dusty textbooks, and YouTube hadn’t yet been invented), the only obstacle standing in the way of adequate immersion is having the discipline to allocate time to it.

Too often, clinicians assume they are advancing their expertise, and fine-tuning performance standards, purely by attending work – clocking in and clocking out, going through the motions on the shop floor, and then completely disengaging during free time. This is occupational autopilot. And it is dangerous.

Screen Shot 2017-03-14 at 20.33.35Occupational autopilot predisposes clinicians to flounder during a crisis, because the mind stiffens when seldom fed new information. For example, the disengaged anaesthetist who rarely ventures far from uncomplicated elective orthopaedics will be flummoxed by the surprise grade 4 intubation. Despite being entirely competent enough to weather the storm, he/she will fall easily into the clutches of the threat mindset and spectacularly fail the patient in that rare moment, largely because of their lack of engagement with the broader landscape of their chosen pursuit.

The ability to think laterally, employ techniques that might be ‘rusty’ or never performed before (e.g. surgical cricothyroidotomy), and trust one’s own clinical judgement, can only occur seamlessly if you have adequately immersed yourself in the educational resources and evolving narrative of your vocation.

Of course, immersion in specific resources to improve an isolated skill is crucial if weakness is identified (a principle of ‘deliberate practice’ – see below). But it’s the habitual (daily) general immersion, with no specific agenda, that is a key characteristic of the dedicated professional whose identity is embedded in his or her craft. Immersion isn’t a training methodology – it is a lifestyle decision. It ensures currency is maintained, and nurtures a fertile cognitive environment, mandatory for yielding the acrobatics and improvisation required during a crisis.

Deliberate Practice

“Skill is only developed by hours and hours of beating on your craft.”

Will Smith, actor

Deliberate practice describes a common set of principles which should form the framework of every training session [1].

Every time you practice, your sole mission is to improve. You should constantly be asking yourself the question: “How can I do this better?”.

A specific component of a chosen skill is isolated – one that you are poor at or can’t do – and then subjected to specific training exercises and repetitions (‘drilling’).

The core principles of deliberate practice:

  1. specific, measurable goal must be established for the session. Vague overall performance targets like ‘succeed’ or ‘get better’ mean nothing.
  2. Be maximally focused on improvement during practice. It must be intense and uninterrupted. Put your electronic device away.
  3. Receive immediate feedback on your performance. Without it, you won’t be able to figure out what you need to modify or how close you are to achieving your goal.
  4. Exit your comfort zone. Push yourself to the edge of what you are capable of. Don’t be afraid of failure – it signposts the path to progression.

IdScreen Shot 2017-03-14 at 20.35.09eally, a supervisor should be present to guide training, and give immediate feedback. When this isn’t available (which will be most of the time for the majority of clinicians), video footage of the skill being performed/taught is a decent substitute. You can compare your own repetitions to the video subject, and ‘self-police’ your training progress. The plethora of FOAMed video content makes this comfortably achievable.

Human nature dictates that we gravitate towards training skills that we are already proficient at, and neglect areas outside our comfort zone. Why? It’s much more satisfying to feel like you are ‘nailing’ something. DO NOT be enticed into that trap – the significant gains exist where there is most discomfort and least enjoyment. What is enjoyable, is the feeling that you are moving forward and advancing your overall proficiency.

Regular re-visiting of skills that have laid dormant for a while (either in practice or in the field) is essential for avoiding skill fade. This habitual ‘spaced repetition’ deeply embeds a skillset into our mental scaffolding, and makes it far more likely to be retrievable under acute, severe stress.

Here is a previous blog which covers deliberate practice in a little more detail.

Visualisation

“In my view, the answer is to use the highest fidelity simulator in the universe – the human brain”

Cliff Reid, Emergency Physician, Sydney HEMS

Despite it being our most powerful and adaptive weapon, we routinely fail to utilise our brain as a training gadget. When physically practicing, our minds are engaged, but (naturally) we conceptualise the process as being entirely external. Our conscious focus is largely zoned in on body positioning or equipment handling, making it easy to forget our brain is the anatomical structure in the driving seat.

tigerwoodsvisualization

Visualisation (or ‘mental practice’/’mental rehearsal’/’imagery’) is the process of consciously playing a mental ‘video’ of a task or scenario from the perspective of one’s own eyes. In other words, one thinks about doing something, step by step. Despite no physical engagement, one is activating the very same neural circuitry as when performing the skill for real, and if done effectively, it reinforces skill-related mental scaffolding, just like deliberate practice [2, 3]. It enhances clarity and speed of thought during the moment of truth.

Much like the concept of mental toughness itself, visualisation can get routinely dismissed as a vague, abstract, somewhat hippyish concept, with little scientific credibility. If that is your opinion, you are sorely mistaken and missing a huge opportunity. The evidence-base is abundant across a wide spectrum of human endeavour, with perhaps the most high profile examples found in the results-driven world of elite sport [4, 5, 6]. Desperate for the edge over equally motivated competition, you would be hard pushed to find an upper echelon-worthy individual or team not dedicating a considerable portion of their training schedule to mental practice. Put simply, it is considered pivotal to producing the goods by folk who earn their living making us say ‘WOW’. When the Federers, Mcilroys, and Bradys of this world consider it indispensable, then frontline healthcare, an equally performance-centric game, should be paying attention.

Vivid realism is crucial for the process to be effective. You need to feel it as well as see it. The PETLEPP mnemonic is a useful guide [7]:

Physical – What are you holding? What are you wearing? What are you smelling?
Environment – What are your surroundings? It is essential to imagine yourself in the environment where you will be performing (i.e. your usual workplace).
Type –Imagery must be specific to your role and responsibility.
Timing – Given the time critical nature of acute care, imagery must take place in ‘real time’.
Learning – Content should evolve with learning. The cognitions and feelings experienced will change as the individual improves.
Emotion – Imagine yourself acutely stressed, but in the challenge mindset. Total ‘calm’ is not realistic and, therefore, not useful.
Perspective – Feel and see from your own perspective (i.e through your own ‘eyes’).

The unique selling point of visualisation when compared to other practice modalities is its malleability. Using your imagination to conjure up potential curveballs and banana skins is a very effective method for finely sharpening routine skills and processes where there may be a tendency to get complacent. Play the ‘what if’ game:

“What if I had to perform an RSI on a 300kg patient with a receding chin? What extra precautions should I take?”

“What if whilst I was putting in a right IJV central line, the patient became hypotensive and the oxygen saturations dropped to 70%? What should my next steps be?”

“What if I was the trauma team leader for a penetrating chest trauma case and suddenly the patient lost output?”

It’s also a perfect strategy for shoring up one’s procedural routine for exceptionally rare events, such as the emergency thoracotomy or perimortem Caesarian section. Procedures like that would be uneconomical, and logistically impossible, to repetitively practice on mannikins/cadavers. Regular and structured mental practice is therefore a must for emergency providers who genuinely want to be able to tackle everything thrown at them. It is impossible to predict what is coming through the resus doors, but when you have seen it all in the simulation lab between your ears, you will be ready.

This technique isn’t limited to skills training; it can be applied on a broader, more personal level as well. It can galvanise the spirit, and ignite the passion for positively affecting the world through your job – a trait abundant in all of us deep down. Regularly visualise yourself returning home at the end of a shift, mission, or deployment with that beautiful sense of victory and euphoria that washes over when you know you’ve performed well. See yourself overcoming every obstacle thrown at you on duty, and always able to access clarity of thought, and the best of your ability, when it really counts.

Capture yourself in the career trajectory exactly as you have always dreamed it, regardless of how far away you currently feel. If you have the imagination to dream, and the courage to believe that your vision is possible, it will make you hungrier to strive for it. Every training session will be laced with boundless intent, and in time, your mental movie will become a reality.

Summary

Effective practice is about building confidence, so that when a performance is required, the challenge mindset is achieved.

Immersion in your craft safeguards against occupational autopilot, and fosters a healthy cognitive environment for high performance.

When training specifics, fully embracing the principles of deliberate practice is the only gateway to expert-level skills.

Visualisation, when maximally vivid and performed in a structured fashion, can prepare you for anything. Never underestimate the training-tool that is your mind.

Building mental toughness isn’t easy, but your patients deserve it. No-one will do it for you. Get after it.

References

  1. Peak: Secrets From the New Science of Expertise. Anders Ericsson and Robert Pool.
  2. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  3. Mike Lauria. EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria. EMCrit Blog. Published on February 21, 2017. Accessed on March 13th 2017. Available at [https://emcrit.org/blogpost/ehpr-part-5-using-mental-practice-visualization-exercises-mike-lauria/].
  4. Feltz DL, Landers The effects of mental practice on motor skill learning and performance: A meta- analysis. Journal of Sport Psychology. 1983;5(1):25-57.
  5. Mental Training for Peak Performance. Steven Ungerleider and Nick Bollettieri.
  6. Sports visualisation: how to imagine your way to success. Mark Bailey, The Telegraph.
  7. Holmes PS, Collins DJ. The PETTLEP Approach to Motor Imagery: A Functional Equivalence Model for Sport Psychologists. J Appl Sport Psychol. 2001; 13(1): 60-83.

‘My Mental Toughness Manifesto’ Part 1: Understanding Cognitive Appraisals

5 Mar, 17 | by rlloyd

It has been an exciting period for me recently. Last month I was at the International Special Training Centre (ISTC) in Pfullendorf, Germany, where I had the honour of speaking to a group of Special Operations Combat Medics in-training from eleven nations across NATO. Staying at the base, meeting the guys, and contributing to their fantastic 26-week course was an unforgettable experience, and without a doubt my most proud achievement to date.

Why me? Last year I blogged/podcasted for St. Emlyn’s about my lively experience working in a South African Township Emergency Department, at Khayelitsha District Hospital. Luckily for me, a course faculty member from the ISTC stumbled across this work and thought I might have something to offer a group of warrior medics.

If you haven’t read the original blog, I would advise that you do before proceeding; the credibility of what follows hinges on its predecessor.

I was tasked with providing a session that tackled human performance optimisation. Through four separate 20-minute lectures, I delivered a package of strategies for ‘Building Mental Toughness’.

This post is a summary of my first lecture at the ISTC, and is the first instalment of a four-post series. I am making a call-to-arms: frontline healthcare providers must start prioritising performance optimisation strategies.

This is my ‘Mental Toughness Manifesto’.

What is Mental Toughness?Roger-Federer-of-Switzerl-007

Traditionally, it’s a term synonymous with the sports world. It is therefore often ignored or laughed off as meaningless cliché, particularly by performers in healthcare – a ‘serious’ field. In my opinion, this represents a glaring missed opportunity.

A mentally tough individual is consistently able to produce desirable performances during moments of high stress; an undeniably crucial trait for those operating in high octane environments, not least the resus room, prehospital environment, or the realm of combat.

By accurately identifying the specific components of mental toughness, we can work on strengthening it through focused training and attitude adjustments. During a stressful, high stakes scenario where a performance is immediately required, (having interrogated the literature [1]) I believe you are mentally tough if able to state the following:

“I am 100% committed”

“I feel challenged”

Commitment to one’s overall goal is critical, but should be a foregone conclusion. A trauma team leader, flight paramedic, or special operations combat medic, should be inherently committed to their job because what they do is of indisputable importance – they deal in the currency of human life. Also, they will have had to demonstrate commitment whilst climbing their respective professional ladders, via examination and selection processes. So, the first half of the battle – ‘being 100% committed’ – is the easy bit.

Feeling ‘challenged’, as opposed to feeling threatened by a stressful scenario, is more complicated. This requires confidence in one’s skillset, and a feeling of control over one’s emotional arousal.

Cognitive Appraisals

It is imperative to appreciate the nuances of acute stress, and how it influences our physiology and cognition.

When an individual is faced with a situation which threatens an important goal (like staying alive, or keeping someone else alive), an immediate two-step cognitive appraisal takes place [2, 3]:

If personal resources are deemed sufficient to meet the demands of the scenario, the ‘challenge appraisal’ ensues. One feels positively energised (‘pumped up’), there is a sense of high self-esteem, and one will view the situation as an opportunity to capture a victorious moment. It is what athletes call being ‘in the zone’. There is physiological stress via activation of the sympathetic nervous system, but control of task-specific motor skills and cognition remains intact.

If the demands outweigh available resources, a ‘threat appraisal’ takes hold. In addition to the sympathetic nervous system response, the hypothalamic-pituitary (HPA) axis activates, triggering the release of cortisol. This cortisol ‘dump’ is a relic from our days as primal hunter-gatherers. It readies the mind and body for instant, evasive action (like running away from a predator), which is, of course, suboptimal when a skilled and complex performance is immediately required.

Threat appraisals narrow our auditory and visual perception, minimise our mental ‘bandwidth’, increase our sense of fear (via its effect on the amydala), erode our short-term memory (hippocampus), and obliterate our capacity for rational judgement (prefrontal cortex) [4].

Need convincing? Watch the video below for an armchair threat appraisal…

 

The psychological literature has consistently demonstrated that high serum cortisol is associated with impaired performance, over a wide range of human pursuit [4, 5]. What becomes clear, therefore, is that performance optimisation centres around this two-step cognitive appraisal process. By using strategies to modify one’s perception of the immediate demands and available resources, we can convert threat appraisals to challenge appraisals, and in doing so, harness the power of the sympathetic nervous system, avoiding HPA axis-mediated self-sabotage.

I will propose seven strategies, over three phases of the game (the ‘practice’, ‘perform’, and ‘process’ phases), designed to favourably modify our perceptions during the cognitive appraisal process. The aim is to build the challenged mindset, resulting in a mentally tougher performer, better equipped for saving lives.

Stay tuned for the next instalment.

Robert Lloyd
@PonderingEM

References

  1. Mike Lauria. Imperturbability: William Osler, Resilience, and Redefining Mental Toughness by Mike Lauria. EMCrit Blog. Published on February 3, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/blogpost/imperturbability-william-osler-resilience-and-redefining-mental-toughness/].
  2. Tomaka, J., Blascovich, J., Kelsey, R. M., & Leitten, C. L. (1993). Subjective, physiological, and behavioral effects of threat and challenge appraisal. Journal of Personality and Social Psychology, 65, 248-260.
  3. LeBlanc, V.R., The effects of acute stress on performance: implications for health professions education. Acad Med, 2009. 84(10 Suppl): p. S25-33.
  4. Scott Weingart. Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset. EMCrit Blog. Published on July 11, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/podcasts/chris-hicks-fog-of-war/].
  5. How stress affects your brain – Madhumita Murgia, TED Ed

*This post has also been published on the Pondering EM blog.

Primary Survey March 2017

23 Feb, 17 | by scarley

It’s March 2017 and time for a quick review of the best of the EMJ this month

Under pressure: does cricoid improve laryngoscopy?

Whether or not we should use cricoid during emergency intubation is fast becoming one of the greatest modern controversies in Emergency Medicine. While we await data from randomised controlled trials, in this month’s issue Caruana et al have provided some important new evidence. In a retrospective analysis of 1195 patients undergoing pre-hospital intubation, cricoid pressure was not found to be associated with difficult laryngoscopy. After propensity score matching, there were no apparent differences in the incidence of complications with or without the use of cricoid pressure, other than an increase in the proportion of patients sustaining airway trauma when cricoid pressure was used. Ultimately we now have further reason to question the routine use of cricoid pressure, but is it sufficient to change your practice?

Statistics made much easier!

Reading the phrase ‘propensity score matching’ may have just made you feel a little uncomfortable. If so, you’re not alone. Most emergency physicians could do with a little help when it comes to interpreting some of the more complicated statistical analyses we encounter in the literature. If you feel that way, I’m sure you’ll be pleased to see that this month we have the first in an occasional series of articles on statistical concepts that go beyond the basics. These articles aim to provide a helpful tutorial to readers to increase their skills of critical appraisal for the future. To help illustrate the concepts, we will link them to original articles that we publish. This month, we’ve linked to the work by Caruana et al, which is free to access as the editor’s choice.

Who calls ambulances and doesn’t wait?

Most of us can appreciate that calling for an emergency ambulance is not to be taken lightly. When emergency services are facing severe and increasing pressure, it can be extremely frustrating to observe that some patients arrive in the Emergency Department by ambulance but don’t wait to be seen. In this issue, Doupe et al explore the characteristics of patients who do just that. Compared with other patients, they found that patients who called an ambulance and did not wait were more likely to have a history of substance abuse ad to live in low income areas. Identifying the characteristics of patients who exhibit this behaviour will help emergency physicians to create individual management plans to deal with apparently unhelpful patterns of seeking healthcare.

A new device to help metrics for ED weighting

Rapidly and accurately estimating the weight of children presenting to the Paediatric Emergency Department is highly important for drug dosing but often challenging. Emergency physicians commonly use formulae or aids such as the Broselow tape. This month, Jung et al report on the accuracy of a novel ‘rolling tape’ electronic device with wireless transmission. They demonstrate that its use enabled faster and more accurate weight estimation than the Broselow tape. However, they go further still: using the rolling tape led to faster orders for resuscitation drugs and defibrillation in cardiac arrest. Could this revolutionise how we measure patients’ weight in the Paediatric Emergency Department?

The trajectory of an academic emergency physician

If you’re a research active emergency physician, you may be interested in tracking your academic progress in relation to other emergency physicians. Is your progress fast or slow? In this issue, Miro et al explore whether we can develop a guide to the progress of researchers in Emergency Medicine. They tracked the h-index of a selected group of academic emergency physicians. The h-index tries to combine an author’s impact with their productivity. If an author has, for example, 5 articles that have been cited 5 times or more, then their h-index is 5. Miro et al have derived a formula to track the rise in h-index for ‘fast’, ‘medium’ and ‘slow’ growth academics. Where do you fit in? Don’t be discouraged, though. All the authors included in this sample were highly reputable academic emergency physicians. Even those in the ‘slow growth’ category may therefore be elite researchers. You may, however, find that this article spurs you on!

Can doctors measure pain in children?

Brudvik et al report a fascinating study in which they asked children to score their pain in the Paediatric Emergency Department, while doctors and parents were asked to estimate the score. How do you think we did? Read the full article to find out the detail, but you may be surprised to find out how much we under-estimate pain and how often we withhold analgesia, even for children with severe pain. It’s a sobering reminder that the pain of an individual is a very personal experience and cannot be accurately measured by others.

vb

Rick Body

PDF

http://dx.doi.org/10.1136/emermed-2016-206657

Are nurses always right?

15 Feb, 17 | by cgray

Are nurses always right?

As a junior doctor, I have had, and still have some fantastic senior colleagues to work with, who generally give important and valuable advice. Over the placements and years, their advice is slowly turning me into the doctor that I aspire to be, an amalgamation of all the good bits from every doctor I have worked with so far along the way. I say doctor, but really I’m talking about all the other people that play a part in the hospital experience. Physiotherapists, pharmacists, health care assistants, porters, and so many more. Most of all, the many brilliant nurses I’ve had the pleasure of working alongside.

When I first started out as a doctor, the single biggest piece of advice that was given to me, and that still holds true today as one that I pass on to those unlucky enough to be my juniors, is to listen to the nurses. Make friends with the nurses. Don’t get on their bad side. Pay attention to what they say. That advice has saved me and saved my patients more times than I can count.

Because, nurses are always right. Aren’t they?

It’s a brave team that would design a study to pit nurses against a scoring tool, but that’s exactly what Allan Cameron and team from Glasgow have been up to. The Glasgow Admission Prediction Score (GAPS) was developed to estimate the probability of a patient being admitted, based on data collected at triage such as the patient’s age, early warning score, and triage category. The tool has been validated with good results, and could be used to help to optimise flow within the ED through early identification of those more likely to need a hospital bed.

This study, published in the January EMJ, aimed to compare GAPS to the triage nurses’ gestalt on likelihood of admission. To assess the latter, a visual analogue scale (VAS) was used, onto which triage nurses would mark how certain they were of patient admission/discharge. Previous studies on the topic have shown that when nurses are confident of the outcome, they’re usually right, and this study was no different. As always, we’d recommend you take a look at the paper itself to draw your own conclusions from the results.

3844 attendances to a single emergency department were studied, however a portion were allocated direct to a minors or resuscitation area, bypassing triage, and further patients were excluded from being under 16 or leaving before treatment was complete. Only 9 patients out of the 2091 that were triaged had insufficient data completion, which is a respectable figure. Of the 1829 attendances suitable for inclusion, 745 were admitted (40.7%), which seems high, however as stated this did not include a large number of minors patients who were more likely to have been discharged.

Nurse gestalt was found to be more sensitive than GAPS (81.2% vs 71.8%) but less specific (77.4% vs 86.6%). There was no correlation between nurse seniority and accuracy of predictions. Whilst the GAPS was more centrally distributed, results from the VAS showed peaks at 0-5% and 95-100% certainty of admission. This was the case for 781 patients. In these patients, nurses performed significantly better than GAPS, correctly predicting outcome in 92.4% (722). Excluding these patients though, GAPS provided a more accurate assessment.

In practice, the team found that the most accurate way to predict likelihood of admission was GAPS, but with the triage nurses able to override the tool where they were confident (>95%) as to whether the patient would be admitted or discharged. The authors admit that more work is needed, but maybe we’ll see admission prediction scores in use in the future.

Interestingly, there is no mention on whether those patients discharged home were followed up to see if any were admitted in the following days. Maybe the nurses’ gut feeling wasn’t wrong after all…

vb

C
@cgraydoc

BBC visit UK emergency department and experience Winter pressures

7 Feb, 17 | by scarley

It’s not really news that UK Emergency departments are under pressure, but those realities are often hidden from the general public. However, in the last week the BBC was granted access to the Royal Blackburn hospital to see first hand how it feels to deliver emergency care in an overcrowded environment.

Follow the link below to see the BBC review.

http://www.bbc.co.uk/news/health-38885775

vb

S

The One-Upping Blind spot.

2 Feb, 17 | by scarley

Sometimes you see things on twitter that upset you. This week I noticed this post from the excellent Shaun Lintern on ‘one-upping’ in hospitals. It’s not a phrase I’ve heard before but it essentially means putting an extra patient on wards above their intended capacity.

Ruth May is the executive director of nursing for the NHS Improvement agency. She is quoted as saying that one upping is not acceptable and that it poses a significant risk to patients. There is little to argue with this but stop and think, what are the consequences for the whole system if one area declines to accept any risk? Does the risk vanish, or does it simply move elsewhere? I suspect that you, like me know that it is the latter.

If one upping is unacceptable does NHS Improvement have any idea what it’s like to work in a UK ED at the moment? Never mind one upping, try 10,11,12,13,14,15 upping your trolley patients. It is so common as to be routine practice in the UK.

Those numbers do not take account of the patients in the waiting rooms who should be on trolleys, but who are on chairs as we’ve run out of trolleys for them to lie on. Is it acceptable to have to give IV opiates to a patient sat on a chair in a corridor with renal colic? Of course not, but that real example is a manifestation of what overcrowding means. It’s incredibly risky for patients as we know that overcrowding causes increased numbers of deaths. Make no doubt about it, overcrowding causes death and disability in our patient populations in the ED.

Ruth May does not state whether her comments apply to the ED and I’m sure she knows about EM overcrowding, but her comments are likely to prevent the sharing of risk across hospitals and services. This could lead to more harm as we know that sharing risk is a positive patient safety move. You should be familiar with Full capacity protocols which are designed to share the load and to avoid the harms that overcrowding causes, but they are yet to catch on in the UK.

Also see www.hospitalovercrowding.com

How on earth can it then be logical to concentrate all that risk in one place, the ED, rather than spread the risk across wards and departments? How can it be wise to ask my team to look after multiple patients on trolleys in corridors as opposed to asking a number of wards to take one extra patient.

It’s illogical, unsafe and dangerous and yet it’s a common strategy in many trusts. The comment above from a UK colleague about crowding this winter will be familiar to many. Corralling the risk in an overcrowded ED is indicative of a hospital that has chosen to concentrate the risk in a single place. It’s bad for patients and it’s bad for staff who burn out as they cope with a deeply unfair, grossly differential and unsustainable workload.

My plea is that when we hear talk of avoiding one upping that it does not inadvertently lead to even greater levels of harm in the ED.

We need strong and vocal leadership to stop this from happening.

vb

S

Primary Survey Feb 2017

30 Jan, 17 | by scarley

Highlights from this issue
Ellen J Weber, Editor in Chief

 

Teaching how to think
Somewhere between entering medical school and leaving specialty training, a young doctor makes a transition from being a complete novice to a physician capable of making diagnostic and treatment decisions more or less independently. How exactly does that happen?

Two articles in this month’s issue, along with a commentary by Damien Roland, attempt to shed some light on this murky metamorphosis. The study by Bowen et al examines  a cross-section of clinicians at different phases in their careers, looking at how decisions are made. In this study, 15 Paediatric Emergency clinicians (consultants, trainees and nurse practitioners) were interviewed about their decision making when treating  patients under 5 with respiratory illness. Junior clinicians were more risk averse, and relied heavily on guidelines and second opinions; experienced physicians appeared to use more tacit knowledge and take more risks.

In this month’s Editor’s Choice selection, Adams et al, studied 37 junior EM doctors who were asked to recall two recent cases and discuss how they approached their clinical decision making. In the language of dual-cognition theory, the authors found that the trainees essentially described that throughout the diagnostic and disposition process, they used so-called Type 1 thinking (intuitive), countered by Type 2 (analytical) thinking to keep themselves and their patients safe. A high level of diagnostic anxiety was seen in this group of doctors. The authors suggest that teachers could do more to prevent premature closure, speed up learning of pattern recognition to decrease cognitive loads, and routinely employ methods of reflection after a case to improve awareness of the reasoning process. They provide a helpful set of questions for the teacher of emergency physician to walk the learner through this process. To bring this all together, Dr Roland’s commentary ‘Have we forgotten to teach how to think?’ challenges us all to consider if we are paying enough attention to this aspect of the transition from novice to expert.

Smile, though your heart is breaking
Arguably, the antithesis of thinking is acting on instinct, or gestalt. Much has recently been made of physician gestalt, with several studies suggesting that physician gestalt is about as good as many tests or decision rules. Jeffrey Kline, who most of us know for his work in pulmonary embolism (PE), and specifically the PERC rule, has an avocation in physician gestalt, questioning what it is about our patients that gives us this ‘sixth sense’ about whether they are sick or not. Some will remember Dr Kline’s EMJ publication in which he demonstrated that patients who are sick (in that case, have a PE or a serious cause of chest pain) have less facial reaction to stimuli than those who are well. Based on this finding, he hypothesized that patients who do more smiling – and physicians perceive as smiling – are less likely to have a serious diagnosis. In this month’s issue, we reveal the results of a study by Kline and colleagues of 208 patients about to undergo a CT scan for pulmonary embolism.  The pretest probability of a PE was estimated using the gestalt method (visual analogue scale, 0%–100%), the Wells score (0–12) and physicians’ impression of whether the patient smiled during the initial examination (smile+). Patients’ faces were also analysed with an automated neural network-based algorithm for happy affect. Without being too much of a spoiler, let’s just say ‘don’t let that smile fool you’. The results may have you rethink your initial  impression of that chipper patient in room 3.

Is it time to embrace the Shock Index?
The Shock Index was introduced in 1967 as a prognostic marker for hemorraghic and infectious shock. It has shown promise as a marker of high risk patientsin several ED studies since then, having  an association with increased lactate, and, in another study, increased incidence of post-intubation hypotension. But the Shock Index has not generally been adopted into routine EM practice. Balhara and colleagues from The Johns Hopkins University School of Medicine studied over 58 000 patients seen in their ED over 12 months, and demonstrated that increasing values of the Shock Index were associated with an increasing likelihood of admission and mortality. An SI of >1.2 was a strong predictor of both inpatient admission and mortality. The Shock Index is remarkably simply to calculate: heart rate/systolic BP. If you can calculate a MAP, you can certainly calculate a shock index!

Candy is dandy, but glucose is quicker
This systematic review by Carlson and colleagues answers the question of whether dietary sugars are as good as oral glucose for patients with hypoglycaemia (and no IV). The simple answer is no, they are not. However, knowing the ‘bottom line’ should not dissuade you from reading this interesting paper, which looks at the effects of some of your favourite confections.

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Ellen Weber

EMJ Editor

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