It was a slow day for Michael Mallin, MD, the director of emergency ultrasound and the director of education at the University of Utah. He was pretty relaxed on his night shift sitting next to the charge nurse's desk when he noticed the triage nurse “scurry a little more rapidly than usual” to describe a patient to the charge nurse.
“I heard her say something about ‘sat's at 48%,’” he recalled speaking at the Blood and Sand conference on resuscitation, airway, and ultrasound a year ago. “I thought, ‘No way is this guy in triage. And if he's that sick, why are they not pushing him back right now?’”
Just then, the patient was wheeled back in a wheelchair, and Dr. Mallin was taken aback by his appearance. “He looked distraught, nervous, like he was working to breathe, but his respiratory rate wasn't that fast,” he said. Dr. Mallin tried to speak to the patient, but the man pushed up out of his wheelchair and threw himself onto the bed. “I realized, this guy was going to die on me. He's been breathing this hard for this long. He's giving up. At first I'm frozen; I wasn't prepared for this.”
Dr. Mallin related a story that, in its essence if not its exact particulars, was probably familiar to every practicing emergency physician: a patient with airway access challenges (in this case, a large, flabby neck), oxygen saturation persistently in the 50s and 60s even with oxygen, a rapidly dropping heart rate, and the moment of paralysis and near-panic when the portable video laryngoscope revealed an airway utterly blocked with massive, swollen epiglottis.
“No way I'm getting a tube past that,” Dr. Mallin recalled thinking. Just then, the man's heart stopped. “Suddenly, I had tunnel vision. Everything in the center of my vision was perfectly clear, but the periphery was completely blurry.
He took a deep breath before plunging into the procedure, hands holding the scalpel trembling. With no visible or palpable landmarks in the man's large neck, Dr. Mallin finally felt the sandpaper of the thyroid cartilage under his blade after about eight slices. “I put the Shiley in, the residents were ready and threw the bag on and started ventilating, and after two minutes of compressions, we looked at the ultrasound, and there was a beautiful, strong heartbeat.”
The tunnel vision retreating, Dr. Mallin walked out of the trauma bay still trembling with the stress of the situation. “I probably could have done things better: made better decisions, performed more quickly, acted more aggressively earlier. I could have not frozen in the first couple of seconds,” he said.
A quick poll of the audience revealed that Dr. Mallin's experience with this patient was almost universal: Virtually everyone agreed that they had at least once cric-ed a patient with a bad airway, and that the experience had been stressful. “The more we recognize that our stress is going to be through the roof, the better we'll be able to cope with that stress in the moment,” Dr. Mallin said.
Preparing for Stress
That is the goal of stress inoculation training, a multifaceted type of cognitive behavioral therapy designed to help individuals cope with stress. The training was developed by psychologist Donald Meichenbaum, PhD, in the 1980s as a way of helping individuals exposed to traumatic experiences cope with pain, anxiety, anger, and fear. But organizations like the military and NASA saw its potential for use as stress prophylaxis and a performance enhancer. The training offers the knowledge, skills, and practice needed for emergency and critical care physicians and other medical professionals who have to make decisions in high-stress situations to be ready to “fight” — treat the patient — rather than freeze when a patient suddenly starts to go south.
Emergency physicians tend to have the cultural belief that they can put such stress aside and not let it affect performance. “Most people's coping strategy for managing performance during an acutely stressful event is just to ignore it,” said Christopher Hicks, MD, MEd, an emergency physician and trauma team leader at St. Michael's Hospital at the University of Toronto. “We have a lack of recognition of how an acutely stressful event impairs your performance: attention, cognition, holding items in your short-term memory for processing, situational awareness, and so on. There's a good body of research to show that all of those things are significantly degraded when stress rises above a particular level called a threat challenge threshold.”
You can't “train” people entirely out of feeling stress when, for example, they are resuscitating a neonate, but you can reset their cognitive set point so they view the situation as challenging rather than threatening. Stress inoculation training isn't just “putting people in crazy stressful scenarios with ridiculous things happening and pushing them really hard,” said Michael Lauria, a critical care flight paramedic, a former member of U.S. Air Force Pararescue, and now a third-year medical student at the Geisel School of Medicine at Dartmouth, who has written about psychological skill training for emergency medical professionals. (Emerg Med Australas 2016;28(5):607; http://bit.ly/EMCritStress.) It has three components:
- Knowledge. “There's some evidence that suggests that just by telling people the physiological facts about stress — this is why you get tunnel vision, this is why you can't remember drug doses or what's next in the algorithm even though you've done it a million times before — goes a long way toward adjusting your expectations and improving performance,” Mr. Lauria said.
- Skill acquisition. This means practicing the psychological and mental skills needed to deal with stress. “Like any other skill — intubating a patient or putting in an IV — you have to practice them over and over again if they are to be of any value,” he said. Those skills can be as simple as the deep breath Dr. Mallin took before beginning the thoracotomy or the words he repeated to himself: “I'm cric-ing this guy.” Athletes do this all the time: Think of Michael Phelps flapping his arms on the starting block before each race or former Yankees pitcher Mike Mussina's deep bend at the waist before each pitch. Athletes also do visualization exercises: seeing themselves diving off the block, moving through the water, doing the flip turn. As Dr. Mallin told the audience at Blood and Sand, functional MRI shows that the same areas of the brain light up when you're mentally rehearsing a task as when you're actually doing that task.
- Simulation. “This is the part where you expose people to stressful scenarios, put them in complicated clinical scenarios such as a difficult congenital anomaly or complex physiology,” Mr. Lauria said. “Maybe you add external stressors like malfunctioning equipment or a combative family member. You don't make it ridiculous, like the Iraqi Army is invading your ED. You do real scenarios that could happen any day in a typical ED.”
Stress inoculation training is not currently a standard part of medical school or residency training in any academic medical center, Dr. Hicks said. “That speaks to the state of medical culture more than anything. There is a presumption that many practitioners develop these skills over time, over five or 10 years, learning to perform under stress by way of habituation,” he said. “But you can't assume that everyone will do this, that junior doctors will just absorb these skills by osmosis without naming them or identifying what they are and deliberately practicing them.”
Testing the Training
The University of Toronto is now engaging in what, to the best of Dr. Hicks' knowledge, appears to be the first funded trial of a stress inoculation training program for emergency medicine and general surgery residents in years PGY2-5, as well as for nurses and respiratory therapists in these areas. Funded by the Society for Academic Emergency Medicine, the half-day program flips the order of stress inoculation training. Residents first go through complex simulated cases in a high-fidelity patient simulator, with scenarios designed to bring out elements of stress they might encounter in the actual clinical environment: diagnostic ambiguity, difficult airways, fire alarms, power failures, and disagreement among providers.
“Then we sit down and debrief as a team and instructor about what we've just been through, what happened to them psychologically and physiologically, and talk about ways to manage the situation in the moment,” said Dr. Hicks. “We teach a script for controlled breathing, and educate them about specific techniques for cognitive reframing: reassessing a situation, using positive self-talk and mental rehearsal to bring you to a better state of focus.”
The study has been ongoing for about a year, and will soon break for an analysis. “It's an interesting thing to watch,” Dr. Hicks said. “Doctors are not used to talking about this stuff, not just emotions and feelings, but how they affect what they do and how good they are at it. But most people think it's an important and different way to approach resuscitation science.”
The study will assess physiological measures of stress among stress inoculation training participants versus those who undergo the program's regular “human factors” curriculum, measuring salivary cortisol before, during, and after a simulated resuscitation. Other measures will include heart rate variability, how much your heart rate varies over a period of time coupled with the acuteness of your stress, he said.
A secondary outcome, which Dr. Hicks said he believes is just as important, is how well the teams perform during these simulated resuscitations, before and after they undergo the training (or the human factors curriculum). Blinded reviewers will score the team-based performance using a validated behavioral ratings scale. “We want to see if the training not only decreases your stress but also improves performance,” he said.
A preliminary study published by Dr. Hicks' group in 2015 in the Canadian Journal of Emergency Medicine found that the “mental practice” component of stress inoculation training did appear to improve performance: the mental practice group outperformed the control group, with a significant effect on teamwork behavior, as measured by the Mayo High Performance Teamwork Scale.
Reaction to stress is probably the thing that most prevents emergency physicians from performing at the top of their game, Dr. Mallin said. “The medicine's not that hard. We can all talk through a cric. But whether you can perform a thoracotomy in real time is all about how well you can compose yourself in the moment, how prepared you are for the adrenaline rush. That's what stress inoculation training is about.”
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