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Primary Survey August 2017.

2 Aug, 17 | by scarley

Clinical pharmacists improve practice in emergency departments

There are 2 studies in this month’s issue which show the benefits of clinical pharmacy input in the setting of an emergency department (ED). One from Spain and one from Belgium. It is a relatively high risk area for drug medication errors as there is a fast turnover of large numbers of patients, the use of drugs which include those with significant toxic effects as well as potentially life threatening impacts, plenty of opportunity of miscommunication and many interruptions to nursing and medical staff whilst carrying out prescribing duties and administrating therapeutic agents. Read the editorial here.

Clinical relevance of pharmacist intervention in an emergency department

The first study looked at the impact of a clinical pharmacist working between 8 am to three pm Monday to Tuesday over a non-consecutive 6 month period in an ED with over 100 000 attendees per year. There was an electronic prescription system and a short stay facility (for 24 hours maximum).

Severity scales that looked at the drug errors and their potential impact of patient’s well-being, the clinical impact of the intervention by the clinical pharmacist were used as outcome measures. About 10% of patients were reviewed, over one fifth of whom were in the short stay facility, of whom 13% were finally admitted to hospital.

The majority of activity was to prescribe drugs that the patient was on at home or to  give  a suitable alternative from the hospital formulary. Other trends noted included the ‘over prescription’ of certain drugs like omeprazole and simvastin. There may have been a Hawthorne  effect as there was not a rise or drop in the error rate of ‘high alert medications and increased errors or interventions’ as compared with other studies.

Developing a decision rule to optimise clinical pharmacist resources for medication reconciliation in the emergency department

The second study produced a clinical decision rule (CDR) for the identification of patients admitted from ED with discrepancy in the initial medical history taking about medications.

This was a study based on looking at 3592 patients and using  variables such as age, gender, the medical discipline who admitted them, when in the year they were admitted and if there were any high risk drugs administered, among other factors. The purpose was to reduce error and to save time in the ED (the gold standard of a complete assessment by a clinical pharmacist was 20 min, with an estimated average number of 20 such assessments being possible in a working shift.

The most common error found in validating this was the omission of drugs that the patient was taken when looking at routine clerkings. In the final CDR chosen for ED, there were the advantages that many of the fields were already included in routine data collection as part of the patient’s journey to being admitted (reducing time and the need for repeated history taking). Key features for future developments are to quantify the potential benefits associated with the use of the CDR from a patient perspective, and as with the first study, health economic modelling would be an important addendum in prospective work.

Validating the Manchester Acute Coronary Syndromes (MACS) and Troponin-only Manchester Acute Coronary Syndromes (T-MACS) rules for the prediction of acute myocardial infarction in patients presenting to the emergency department with chest pain

This observational study was to validate and compare both rules in an Australia and New Zealand ED settings. The results showed that both could determine low risk patients, with sensitivity results of 99%, MACE identifying 10.7% and T-MACS in 19.8% of patients with acute MI at 30 days.

‘The year of first aid’: effectiveness of a 3 day first aid programme for 7–14 year-old primary school children

Can you teach young children adult BLS, use an AED, managing an unconscious patient, deal with haemorrhage and calling for an ambulance?

The answer is yes to most of the parameters recorded- after teaching, by theoretical knowledge and skill teaching, there was a marked improvement in the delivery of performing BLS including giving ventilation and chest compressions and using of an AED in over 90% of children. The height, weight, age and BMI played a part in the ability to deliver adequate force required to have chest compressions. This is not surprising, given the change in muscle bulk and maturation of the fibre types with the onset of adolescence. This links to the annual Restart a Heart Day on 16th October when children across Europe are taught basic life support (www.erc.edu; www.resus.org.uk/events/rsah)- in the UK, last year over 150 000 children received training. The conclusions of the article that ‘beginning first aid education in schools is strongly recommended’ should be legally mandated- other studies have shown that although very young children may not be physically capable of producing adequate force for chest compressions, they are able to instruct others (and often teach their parents at home what to do, after learning about it at school!)

Emergency department care of childhood epistaxis

What works? This review looks at 32 articles after a comprehensive literature search and provides a framework of treating active and recurrent nose bleeding. A very practical and useful guide to a common problem.

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Ian K Maconochie, Deputy Editor

Olympians and Comedians #PerformanceLDN

28 Jun, 17 | by rlloyd

Traditionally, human factors and performance psychology are low down the priority list (or non-existent) in medical training. Students graduate from medical school with ‘academic-style’ mindsets, arguably ill-prepared for the practical, performance-dependent branches of medicine. In short, our training predisposes us to the yips.

But change is afoot. On 24th June, I attended the London Performance Psychology Symposium at the Blizard Institute, close to the Royal London Hospital. Organised by the London Air Ambulance Service, it was the world’s first medicine-specific performance psychology conference. For a Kool-Aid drinker like me (I’ve blogged on mindset and performance here at the EMJ and over at St. Emlyn’s), it was unmissable.

The line-up included a Who’s Who of thought-leaders from the EM/critical care/prehospital community, along with elite performers in distant disciplines. All were united in their quest for performance optimisation. The day was jam-packed full of pearls, but my favourite take-home points came from the worlds of sport and stand-up comedy.

‘Focus on your processes’

The audience was inspired and riveted in equal measure when Olympic rower Mel Wilson delivered a TED-worthy presentation on the performance culture of the GB Women’s VIII at Rio 2016. Her message was beautifully simple:

Focus on your processes, not the outcome

She kept returning to this mantra. You have no direct control over the outcome of a rowing regatta, much like you have no direct control over patient survival from life-threatening illness or injury. There is always the chance, whether racing a boat or team-leading a paediatric cardiac arrest, that winning will elude you, despite performing at your maximum. The only controllable elements are how diligently you approach the steps required, and how well you sync up with your team. By placing all your focus on real-time practicalities (processes), as opposed to the overall goal, the result will usually take care of itself.

Fascinatingly, when Mel started to feel stressed or overwhelmed by the moment, it would physically manifest as a specific hand/grip position on her oar. When she noticed that happening, she would use it as a trigger for re-directing her attention to her basic processes and nothing else, which nipped any potential cognitive or physiological self-sabotage in the bud. This strategy can be applied to resuscitation. When a case becomes chaotic and unmanageable for the team leader, it should trigger a cognitive stop-point. That moment is an opportunity to summarise the case thus far (sharing his/her mental model) and to focus the team’s attention on crucial basics – e.g. good quality CPR, rhythm and pulse check logistics, a recap on interventions performed and when the next is due (e.g. next adrenaline push) etc. Reigning in the team from a state of entropy is achieved by getting back to basics. Once order has been established, more nuanced performance and clinical reasoning can be layered on top.

Team-GB-621915The reality for athletes, particularly in Olympics-centric sports such as rowing, is that 4-year training cylces culminate is as little as 6 minutes’ peak performance time. That is pressure of unmeasurable magnitude, and the danger of choking is real. In the 2016 Olympic final the crew were in last place until past the half-way mark and Mel described how she resisted the temptation to fixate on their position or obsess about how much time and energy she had invested in that short moment. Instead she focused only on her processes. She felt the team’s collective processes ‘strengthening’ as the race progressed, and in the final stretch they managed to pip the Romanians into third place and seize a historic silver medal. By taking complete ownership of the basic practicalities of their jobs and focusing on nothing else, they achieved sporting immortality.

In medicine, we do not have to wait four years for a big performance to be required – it is an everyday occurrence. But the same rule applies. We must take full ownership over our performance and never allow personal standards to drop because of perceived external pressures. If we resist the urge to dwell on how high the stakes are, how busy the department is, or the implications of a poor patient outcome, and remain doggedly focused on our processes, we will be better doctors.

Mel’s source of inspiration was her teammate and role model, five-time Olympian, Fran Houghton. Fran always claimed that rowing was an ‘art form to be mastered, not a series of races to be won’. Focusing on processes was such a core of Fran’s race mentality, that she is on record as saying she would rather lose with processes intact than win ugly. For an individual whose career will largely be judged on the number of medals won and nothing else, her attitude speaks volumes. Fran has recently retired as one of Great Britain’s most decorated female rowers, and her influence on Mel’s career was palpable.

Perhaps medicine is an art form to be mastered, not a series of patients to be saved. Whilst I am sure that reflection might not jive with how many doctors feel about their jobs overall, I firmly believe that the more we focus on our processes, as opposed to saving lives, the more lives we will save. We must recognise that medicine is a performance-dependent pursuit, particularly on the frontline, and our focus must be on ourselves before the patient, so that we can serve them to the best of our ability.

At the end of my career, I hope I will be able to reflect on a consistently diligent and disciplined approach to my performance at work, and an insistence on respecting the crucial basics, rather than on specific patients with good outcomes or any accolades won/prestige posts earned (still pending obviously!). I would like to think Mel and Fran would approve of that intention.

Best of luck to Mel who is now an FY1 (first year intern) at Hillingdon Hospital. It will be fascinating to see where she ends up.

‘Learning stand-up is like learning to play piano with a live audience’

Another standout moment of the day was when Dr. Tom Evens (London HEMS consultant, and Symposium Convenor) interviewed comedians Milton Jones and Sally Phillips. They were predictably hilarious, with my favourite gag being Milton’s opener:

I’m humbled to be here… a bit like a bird at an airport

I loved the contrast of having professionally funny people talking to a room full of serious types at a serious conference! They made the event feel beautifully light on its feet, whilst making hugely valuable contributions to the overarching conference themes of innovation and exploration.

My take home message from this session is that failure is important, and must be embraced, no matter how painful. Junior stand-up comedians spend night after night failing to make people laugh, but each of those failures is critical for eventual success. A poorly executed delivery or subject matter that falls on deaf ears provides invaluable guidance for iterating the following performance. Eventually, a hilarious session of comedy will have been sculpted from rubble.

I’ve blogged before about ‘Black Box Thinking’, and how healthcare has much to learn from the staggeringly brilliant aviation industry in terms of institutional attitudes towards failure and near-misses. The world of stand-up comedy might provide equally poignant insights. Comedians have nowhere to hide when they are bombing on stage, and it must feel like the loneliest place imaginable. I’ve heard it is the only job in the world where you are judged every five seconds. And yet they keep dusting themselves off and getting back on the horse, knowing that each tumbleweed moment, hurtful heckle or stuttered punchline, is a rite of passage and necessary self-harm en route to mastery. Without constantly putting themselves in a position to fail, and then honestly and actively reflecting post-failure, a comedian’s career would never get out of first gear.

milton jonesThe unfortunate reality of medicine, unlike the comedy club, is that there are plenty of places to hide when we fail, and so precious learning opportunities are frequently squandered. If elite performance is what they seek, junior doctors must take a leaf out of the stand-up comedy playbook and actively chase after moments of failure. Wrong decisions, bodged procedures and impossibly stupid questions should be celebrated for their lessons, and never be deemed unforgivable by supervising senior colleagues, the inherent nurturers of this process.

A novel way that Milton demonstrates mistake-ownership during his routine is to lead a collective ‘boo’ from the crowd when a gag falls flat (‘on three, everybody boo… one, two, three…’). He says it puts his audience at ease, and earns him a sure-fire laugh. What a pro. Mind you, I’m not sure I’ll adopt that strategy the next time I intubate the oesophagus!

Many thanks Dr. Evens and his team for a fantastic day of learning and inspiration. I’m already excited to see who they line up to speak next year.

Rob
@PonderingEM

Primary Survey July 2017

20 Jun, 17 | by scarley

Last winter was a difficult Winter for Emergency Medicine (EM), ED and the staff who work within them. The unacceptable pressures that faced us have only partly gone away and many of us have probably not fully recovered. Stress levels were high, dissatisfaction wide spread, the patients kept coming, and few appeared to leave.

As the year rushes by and Winter can be seen on the not too distant horizon, this themed issue of the EMJ is timely and of significant relevance in focussing upon stress, psychological well-being and job satisfaction amongst a range of Emergency Department staff from both within this country and abroad. Four articles examine this subject and are supported by an excellent commentary from Liz Crowe and her colleagues.

Emergency medicine is a great career:

The first article is a qualitative narrative study interviewing a small number of Consultants from a variety of large EDs in Wales. The study was undertaken to deter- mine their views on both the positive and negative aspects of their jobs and to inform prospective trainees of the attractions of a career in EM. Reassuringly, and despite the pressures of the job, most Consultants were positive about EM, citing a range of factors to justify their opinions. Perhaps surprisingly, all were positive about a Consultants work-life balance, a view contrary to that held by both EM and non-EM trainees, a view that we need to promote to all students and trainees to consider EM as a viable career option.

EM consultant well being

The second paper by Fitzgerald et al is a further qualitative study, this time of a larger representative group of Consultants from the South West of England. The authors this time set out to determine the perceptions that EM Consultants have of their psychological health, factors that impact on this and how they attempted to cope with the pressures of being an EM Doctor. There is much within this paper of importance but for me the negative effect of external organisational issues on the well-being of EM Consultants stood out. This paper should be read by managers as well as Emergency Medics.

A view from abroad

Demonstrating that stress and job dissatisfaction are not unique to UK Emer- gency Departments, the paper by Jiang et al examines the rates of career satisfaction and burnout in a large group of ED nurses from China. In a questionnaire survey with an impressively high response rate, they showed that despite a relatively high percentage of nurses being satisfied with their jobs, there was a high level of burnout with worryingly, almost one in four nurses stating that they were likely to leave their job in the next year. While there may have been some cultural differences behind these findings, the study clearly showed again the relationship between the working environment and levels of stress and burnout.

It’s Not Us, It’s the Organisation

Finally, the systematic review by Basu et al from Sheffield brings together the existing literature on organisational issues that may negatively impact on the psychological well-being of ED staff, as well as adversely affecting their ability to care for their patients which ultimately results in burnout and early retirement. The authors decided to focus on organisational stressors rather than individual vulnerabilities as they felt that these were more likely to be amenable to change. The review found that, common to other specialties, high workload and work intensity as well as long hours negatively impacted on the staff’s psychological well-being and feelings of burnout. In addition, low levels of support from managers and non-ED colleagues, lack of professional recogni- tion and lack of educational opportunities were all important additional contributors not only to psychological well-being but also to compassion fatigue and the ability to care for our patients. While the authors found that studies examining interven- tions designed to alleviate organisational stress were lacking, the evidence presented provides an excellent base to develop interventions at an organisational level to support all ED staff, both in the short term and the long term.

The positive effect of GP’s reducing ED attendances

Undoubtedly one intervention that helps all ED staff is a reduction in the numbers of patients that are seen within an ED. An interesting study from the West Midlands examined the effect of a pre-hospital partnership between ambulance staff and GP’s. GP’s, according to pre-defined call criteria, either provided telephone advice and support to paramedics or attended patients at scene. Almost 10% of calls were able to be handled by GP’s with 80% of these patients not requiring subsequent transport to an ED. The sustainability of this project is supported by it continuing to function 4 years after its initiation.

Too hot, too quick

There appears to be increasing evidence that higher oxygen concentrations during resuscitative processes may lead to harm. This now appears to extend to the use of external exothermic warming devices used pre-dominantly in the pre-hospital setting. I must admit I wasn’t fully aware of these devices designed to externally warm patients, let alone being aware of the oxidative chemical reactions that are used to generate heat. In a neat mannequin study, designed to simulate the use of higher concentrations of inspired oxygen in an enclosed environment, the study by Brooks and Deakin clearly shows that the use of higher inspired oxygen concentrations not only accelerate the exothermic reactions used in the warming devices but result in excessively high temperatures that may lead to clinically significant burns.

Why Patients take the bus

Finally, a paper from Australia, examining the effect of a public health campaign on the use of Emergency Medical Services to transport patients with an Acute Coronary Syndrome to hospital. While the majority of patients with an ACS recalled seeing the campaign, disappointingly the campaign appeared to be unable to influence patients’ behaviour, with over 40% of patients using alternatives to EMS, believing them to be faster than waiting for an ambulance. The authors conclude that further efforts are necessary to inform the public of the medical benefits of EMS transport.

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Richard Parris

 

 

Primary Survey June 2017.

8 Jun, 17 | by scarley

This month’s editor’s choice is actually a pair of papers: one, a study on the diagnostic characteristics of the T-MACS chest pain risk stratification score AND the other, a paper explaining a key methodological concept used in this and other studies of diagnostic tests, the receiving operator characteristic ROC) curve (Richard Body (an associate editor of EMJ) and colleagues previously developed the MACS rule, which classifies patients as very low risk or very high risk after the results of an initial set of biomarkers are known, TMACS relies on obtaining both high sensitivity troponin and heart-type fatty acid, but the latter biomarker not widely available. A modified rule, the MACS score, uses only high-sensitivity troponin and in the current study the authors evaluate this new rule’s test characteristics, using the ROC curve. Hui Zhe Hoo, Clinical Research Fellow at the University of Sheffield and a respiratory physician, explains the fundamentals of the ROC curve using this paper as an example. This is the third in EMJ’s occasional series of articles explaining statistical concepts frequently found in the emergency medicine literature.

Still a cinderella service

Demand for mental healthcare in the ED continues to rise. Sadly this rise increasingly includes children and the provision of child and adolescent mental health services (CAMHS) in most emergency departments falls well short of what is needed. Thus, a systemic review in this issue by Newton and colleagues from Canada on children’s mental health crises in the ED makes interesting reading. A previous review undertaken by these authors in 2010 provided some evidence to support the use of specialised care models to reduce hospitalisation, return ED visits and length of ED stay. In the current study they report increase in research over the past few years, yet most of the evidence is limited by weak methodology. It is evident that the specialised resources and skills needed are still not readily available and the authors reiterate the need for high quality evidence to guide mental health screening, early and effective interventions and on-going follow-up care after an ED visit. I suspect few of us would dispute this view.

Ladders or smiley faces?

Accurate assessment of pain due to an acute injury can be challenging especially when the child is distressed and anxious, but providing timely and effective analgesia is key to child and carer comfort and satisfaction.This issue includes an interesting paper by Ffion James and colleagues from Wales who set out to assess the inter-rater agreement of the Royal College of Emergency Medicine (RCEM) composite pain scale. The majority of pain assessment tools for children were designed for post-operative or chronic pain and not for sudden and acute pain due to injury. The RCEM composite tool combines the numerical rating scale (Ladder), a modified Wong –Baker Faces Pain Scale (Faces scale) and a Behaviour score which groups pain into four categories based on severity. To date the reliability of this scale has not been assessed. In their study, pain severity was assessed by the triage nurse doctor and child (depending on their age) using the composite pain scale. The Faces Scale demonstrated greater inter-rater agreement than the Behaviour Scale, while the Ladder demonstrated poor inter- rater agreement in comparison with the Behaviour score. The authors conclude the Ladder score could be omitted from this composite tool.

Using emergency data for public health interventions

Two studies in this issue demonstrate how data from emergency care can be used to inform public health interventions. Acute and chronic alcohol intoxication, a worrying global public health issue, is the cause of many health and social problems. Reunion Island in the South West Indian ocean is no exception. Reunion Island is among the four French regions where premature mortality due to alcoholism and cirrhosis is the highest and foetal alcohol syndrome is seven times higher than that of metropolitan France. Vilain and colleagues undertook an exploratory analysis based on syndromic surveillance data to describe the emergency department visits for alcohol intoxication and factors associated with their variation. Alcohol intoxication attendances were the second most common reason for ED attendances after trauma and these attendances increased significantly on benefit payday, weekends and public holidays. The authors conclude this kind of syndromic surveillance system for monitoring public health data other than infectious diseases can be used to inform initiatives to reduce morbidity and mortality from alcohol intoxication.

According to the WHO, interpersonal violence accounts for around half a million deaths a year globally. This figure will come as no surprise to ED clinicians and may even be regarded as conservative by those caring for victims on a daily basis. Addressing violence has traditionally been a police concern, so it was interesting to read of a cross sectional study by Quigg and colleagues in the UK which explored the potential of ambulance call out data in understanding patterns of violence to inform prevention activity. This paper is well worth a read as ED’s will see similar trajectories and trends. The majority of call outs were at night for young males in deprived and urban areas, and these calls increased on weekends and bank holidays but not for sporting events. 77.3% were assault/sexual assault while 22.7% were stab/gunshot/penetrating trauma. Interestingly, there were significant differences in call out characteristics between the two violence types. The authors conclude that ambulance call out data provides a rich source of information and sharing this data could be key in violence prevention programmes. Any information that can contribute to violence prevention programmes has to be worthy of consideration.

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Mary Dawood

 

‘My Mental Toughness Manifesto’ Part 4: PROCESS

30 May, 17 | by rlloyd

passenger-plane-landed-in-hudson-river-136395463010203901-150114153840

Everything in aviation we know because someone somewhere died… We have purchased, at great cost, lessons literally bought with blood… We cannot have the moral failure of forgetting these lessons and have to relearn them.”

Sully Sullenberger
Pilot of Flight 1549, ‘The Miracle on the Hudson’

All frontline healthcare warriors will bear scars from emotionally distressing experiences in the workplace (e.g. major incidents with multiple casualties, unsuccessful paediatric resuscitations, personal mistakes resulting in patient harm). For the most part, members of the public will only rehearse being exposed to these flavours of horror by watching movies or having nightmares. For us, it is a potential reality every shift.

In the aftermath, the way one processes these events heavily influences future commitment to similar causes and cognitive appraisals (challenge vs threat mindset) – the key determinants of mental toughness.

Adaptive processing should incorporate ‘Black Box Thinking’ and self-compassion. 

‘Black Box Thinking’

BBT betterConsider the aviation vs healthcare discussion for a moment – arguably the two most safety-critical industries in the world.

On average, just one commercial flight goes down for every 8.3 million take-offs worldwide. In the US alone, there are approximately 400, 000 avoidable medical errors every year, which is the equivalent of two jumbo jet crashes every day [1, 2]. That is a gargantuan discrepancy in passenger versus patient safety.

Of course, it is well documented that the two industries are not directly comparable. There are far more reasons for a patient to die than there are varieties of plane crash, and medics do not yet have the option to switch on a mental bandwidth-sparing machine that’s able to mop up routine tasks. Nonetheless, the statistics illustrate an indisputable point – we have a huge amount to learn from our aviation counterparts, whether we like it or not.

Why is aviation such a staggeringly high performance industry? The answer is simple: there is an institutional culture of learning from failure. Every plane is equipped with two sturdy black boxes which record conversation in the cockpit, and electronic decision-making (i.e. which buttons were pushed). In the case of an accident, the black boxes are promptly retrieved from the battered fuselage, opened, and the contained data interrogated. Every aspect of the crash gets the fine-tooth-comb-treatment to identify exactly what went wrong. Protocols are subsequently modified so the same mistake can never happen again. Error is not viewed as a sign of weakness or inadequacy – on the contrary, it is treated as a precious (even exciting) learning opportunity for everyone who might benefit.

Healthcare culture is largely the polar-opposite. Failure is stigmatised because doctors are supposed to be infallible in the eyes of the public. Mistakes get ‘swept under the carpet’ by the guilty to avoid being held accountable and where that is not possible, the blame-game ensues [3]. When one’s professional credibility is at stake, a successful escape from the situation is higher up the priority list than learning from the failure; and the omnipresent threat of litigation only serves to further entrench this defensive, maladaptive institutional culture. The immediate gratification of reputation-preservation trumps the potential for professional growth that naturally follows acknowledgement of personal failure. We routinely blind ourselves to the best possible signposting for getting better at our jobs – our mistakes.

Whilst this growth-stunting phenomenon will vary in severity across the spectrum of healthcare environments, you would be hard-pressed to find a doctor, anywhere in the world, not regularly exposed to this embarrassing peculiarity of our profession.

Be a black box thinker. Own your mistakes. Share your lessons. Interrogate every performance with the curiosity and tenacity of the Air Accidents Investigation Branch. Re-conceptualise your relationship with failure so that it no longer represents an existential threat, but acts as a guide for your ‘practice’ phase.

‘Reflective practice’ is an overused and misunderstood term in medical training (in my opinion). Often, written evidence of it is a requirement for career progression, and when one ‘reflects’ for that reason alone, it ceases to be useful. Furthermore, documented reflections will too frequently centre around what went well – a less lucrative training exercise.

Apply the black box philosophy to your reflective practice and force yourself to face potentially ugly truths. Embrace being criticised and never back down from asking a ‘stupid question’ – it tees you up for focused training and subsequent accelerated improvement. Have the bravery to be the detective leading the warts-and-all investigation on yourself.

Self-Compassion

In frontline healthcare, we are routinely exposed to life-changing injury and acute illness. If we take our workplace goggles off, and dare to view the worst aspects of our jobs through the eyes of a ‘normal’ person, it can be intensely disturbing. Furthermore, subscribing to the highest professional standards can make us prone to gratuitous suffering as we’ll mistakenly convince ourselves that we could have done more for unsalvageable patients. Our keenness to take full responsibility can render us vulnerable to unnecessary self-punishment.

Without appropriate perspective and personal support, our view of the world, and indeed of ourselves, can become warped. Long-term self-neglect in our line of work will eat away at our commitment to the job, potentially invite long-term psychological damage (PTSD), and ultimately, harm our patients.

When a particularly traumatising incident occurs, many institutions will employ a ‘critical incident stress management’ (CISM) protocol, which encompasses a range of supportive interventions aimed at preventing PTSD [4]. This includes a formal group debrief, led by an outside party (usually a psychologist), within 72 hours of the event. Despite being widely practiced, this approach is controversial as no definitive benefit has been demonstrated in the literature. However, widely accepted to be of critical importance for psychological wellbeing in the immediate aftermath of an emotionally traumatising incident is a ‘defusion’ process [4, 5, 6].

‘Defusion’ is a team get-together where thoughts and feelings are shared in confidence. When threat appraisals drench our brains in cortisol and distort our perceptions, defusion allows for piecing together the chronology and specifics of the event through organic, informal discussion with team-mates. It is an opportunity for emotional support, having a collective laugh/cry at the absurdity of the job, and an accurate information gathering exercise in a safe environment. The team pull together in the aftermath, are honest about their emotional frailties, and find strength in each other. It lacks the rigidity and intrusion of an uninvited formal debrief led by an ‘outsider’.

Pain shared = pain divided

Joy shared = joy multiplied [7]

In the hospital setting, it can be as simple as insisting on a chat in the coffee room after a big resus, or a quick get-together after work. It might seem minor, but unnecessary guilt, anger, confusion and other damaging emotions can be thwarted by this process. However informal and insignificant it might appear on the surface, it is of fundamental importance, and must be sought out, however logistically difficult.

In more extreme environments, such as combat or the prehospital setting, sitting down to defuse should also be used as an opportunity to regain a feeling of physical safety, get warm, hydrate and refuel (eat something).

Self-compassion via defusion is a critical strategy for building mental toughness. Taking care of yourself and your team after an acute insult preserves commitment to the job, and prevents lasting psychological scars that will render you less able to cope emotionally with the inevitable acute stress that lies in wait.

Summary

Use mistakes as signposts for self-advancement as opposed to sources of embarrassment. Own your failures instead of hiding them, and use them to guide your ‘practice’ phase.

Always remember to ‘defuse’ with your team after emotionally challenging cases/incidents. Share the pain, and multiply the joy. Never underestimate the therapeutic value, and heavy dose of perspective, that humour offers.

‘My Mental Toughness Manifesto’ Roundup

You are mentally tough if able to state the following (Part 1):

“I am 100% committed”

“I feel challenged”

To build and maintain mental toughness, I propose seven strategies over three phases of the game:

‘Practice’ (Part 2)

  • Immersion
  • Deliberate Practice
  • Visualisation

‘Perform’ (Part 3)

  • Tactical Breathing
  • Cognitive Reframing

‘Process’ (Part 4)

  • ‘Black Box Thinking’
  • Self-compassion

Own your performance.

Robert Lloyd
@PonderingEM

References

  1. Black Box Thinking. Matthew Syed.
  2. 2017 Royal Society of Medicine Easter Lecture: Creating a high performance revolution in healthcare. Matthew Syed.
  3. What do Emergency Medicine and Donald. J Trump have in common? Robert Lloyd, EMJ Blog.
  4. Mental health response to disasters and other critical incidents. BMJ Best Practice.
  5. Debriefing and Defusing. http://www.davellen.com/page21.htm
  6. Shoes, Sex and Secrets: Stress in EMS. Ashley Liebig. SMACC Chicago lecture.
  7. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.

‘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.

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