Today I am joined by the master of all things Mind of the Resuscitationist, Cliff Reid of resus.me and the Rage Podcast. In the first ever EMCrit Book Club, we discuss a book I read years ago and recently reread:
On Combat by Dave Grossman has enormous relevance to resuscitationists. I feel the entire book is worth reading, but we zoned in on the really juicy bits.
Section I – Physiology of Combat
Chapter Two – Stress Responses to Combat
We briefly discuss bowel and bladder control as they relate to stress
Chapter Three – Sympathetic & Parasympathetic Responses
Parasympathetic backlash-a time of cognitive danger
“The moment of greatest vulnerability is the instant immediately after victory” –Napoleon
Adapt a 360 degree visual sweep for threats (keep looking at all of your patients vitals and remember to bag)
SWAT Team Acronym-L.A.C.E. liquids, ammunition, casualties, equipment; For us–check your team, immediate reset of resus bay, drink something, debrief
Burn off the adrenaline dump
Conflict with colleagues. Exercise, Punching Bags? If a horrible call is reported on the EMS phone, but never shows–run a sim to burn the epi.
Sleep Deprivation-Caffeine can be our friend, nicotine not so much. If you are too exhausted to perform, tell a colleague and take a nap.
Chapter Four – Colored Conditions
originally from Bruce Siddle, Sharpening the Warriors Edge
Heart rate and task performance: heart rates are a guide, getting there by exercise is not the same as by fear/stress, so HR is merely an associated marker
Yellow 90-120, Over 115 and fine motor skills performance degrades significantly
Red 120-150, a 145 HR seems to be the break-point for optimal performance of complex skills
Black >150 and badness ensues, (or >175 in the highly trained, they get a gray zone)
- Fine motor skills-precision tasks
- Gross Motor Skills-ape skills
- Complex-a combination of maneuvers or use of multiple body parts
SWAT team breaking down door function in condition red (or gray), but they have trained until the necessary tasks that require fine motor have been practiced till automaticity
Unified Model of Stress and Performance
We need to train how we fight
Stress Inoculation Training and (Academic Medicine 2009;84(10):S25)
We are currently wasting high fidelity simulation, it should purely be for stress training. Perhaps, we should create a hell week for our 2nd years.
Stay in yellow (alert, but with fine motor control) – yellow dot stickers to remind you
“I understand a fury in your words, but not the words” –Shakespeare from Othello
Tactical/combat breathing to stay in the color zone
Hicks’ Law – procedures should only be learned one way-preflush central lines, one way to RSI.
Section 2 – Perceptual Distortions
Chapter 1 – Auditory exclusion and tunnel vision
tunnel vision – the toilet paper tube
Chapter 2 – Auto-pilot
What is drilled in during training comes out the other end in combat, no more no less
Chapter 3 – Grab Bag
Time perception is sent awry
This is why you must not squeeze a BVM when stressed.
Chapter 4 – Memory
Memories under Stress are Suspect
Self Debriefing is flawed, debrief with your team.
Section 3 – The Call to Combat
Chapter 2 – Training warriors
Need to train the puppy brain, because the doggy will be in control
Triune Model of the Brain
- Forebrain-Human
- Midbrain-Puppy
- Hindbrain-Lizard
Cleanse denial: not if, only when. Do not train to “If I get into a CICO situation,” instead, “When I get into a CICO situation.”
“In combat you do not rise to the occasion, you sink to the level of your training.” –Grossman
Principles of Training
- Never Kill a Warrior in Training-this only trains them to die. Every engagement should end in the proper behavior
- Try to never send a loser off your training site
- Never talk trash about your students-Punish in private, Praise in public
This is a great chapter for folks running courses/simulations
Section 4 – The Price of Combat
Chapter 5 – Tactical Breathing
Autogenic / Tactical / Combat Breathing
4x4x4x4x4
- Breath in through your nose filling up your belly for 4 seconds
- Hold for 4 seconds
- Exhale through your mouth for 4 seconds
- Hold for 4 seconds
- Repeat x 4
aka square breathing
See the EXhalr Site
If you read the book and have thoughts, please leave them in the comments below
Now on to the Podcast…
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Scott Weingart
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Hi, my name is Scott Weingart.
Thanks for finding and sharing it. “on combat” is a very powerful book, a must read for everyone who needs to preform under stress. Really helped me understand myself and others.
thanks, Nathan
Great book and a great discussion – thanks for the recommendation Scott.
Here’s an acronym for you:
The Post-resus mantra: ensure loose ends TIED up!
Team check
Imbibe/ ingest
Equipment resupply
Debrief
Cheers
Chris
just perfect!!
Really, really great. Kudos to Weingart/Reid for sharing- tied together a lot of loose musings in my head. Gonna let it marinate a bit.
look forward to hearing my friend
David Grossman’s book was required reading for us (1 PPCLI) before my battalion deployed overseas to Afghanistan in 2006. We were lucky enough to have the Lt Col come and present the key aspects of his work to the Battalion leadership. It’s a great read, and I couldn’t agree more with the philosophy of training as we fight. I’m looking forward to listening to this podcast.
please come back and let us know how we did
The Minh Writes:
Great podcast guys! I was a bit skeptical on the book and topic but you and Cliff do a good job of making some key points
Certainly the martial arts training helps as you both cite.
I once saw a documentary on British soldiers training on applying prehosp tourniquets and the instructor used a novel technique on making the students run a 100m sprint prior to practising the tourniquet
That is good way to simulate that adrenaline surge
On stress inoculation training , I agree with Cliff . You need to find a balance between making the training stressful and avoid making it overwhelming
I know we need to train realistically but let’s be real… Most of us do not work in military settings . The ED is not prehospital and civilian work as doctors is not on the battlefields
We also need to be aware of the high rates of mental stress disorders when folks work in high stress environments and in fact Grossman devotes a part of the book on this
This occurs despite as much stress inoculation exposure simulation training as soldiers can get ?
exercise is good b/c you learn to deal with shaky hands, but learning to deal with fear is even more important.
Indeed my friend!
I like Mike Tysons take on fear and dealing with stress ” Everyone has a plan until the first punch to the face”
yep!
here is me and my son in our Hell week training ( photo of us going under the tyres, my son is the small boy in the foreground of shot)
http://www.cairnspost.com.au/lifestyle/wet-and-wild-as-far-northerners-get-down-and-dirty-at-adventures-on-a-summers-weekend-festival/story-fnjpuwet-1226835641481
how were you replying to tweets when that photo was taken?
Such a fabulous podcast chaps, on an obviously extraordinary and insightful book. I have mused over it, and the gender specificity in some of the acute stress responses described. Yes, I know, can of worms just opened. There is some discussion that women biologically feel and deal with stress differently than males (the suggested ‘tend and befriend’ vs ‘fight or flight’) This may or may not be true, but anecdotally one does see instances where males and females respond quite differently in these high stress resuscitations. I have no argument whatsoever with Dave Grossman’s excellent translation of experience into practicalities, and the incredibly useful translations that you have both employed in shifting these aspects into the resuscitation room. Most of this stuff rings very true, and should be required listening for all ‘resuscitationists’, male or female, in particular the stress inoculation, the Sydney HEMS reductionist RSIs to eliminate errors of stress, accuracy of memory, post resus TIED up (nice one, Chris) and different grades of SIM fidelity.
These are musings only, (no intention at all of igniting gender wars), but I do wonder whether other females who lead high level resuscitation situations will also read this differently, and wonder what the female equivalent of these stress responses are.
*hunkers down, prepares for gender armageddon*
And please do not misconstrue this as me saying that females are superior (I’m looking at you, Minh) as, in fact, I had the opposite in mind when penning the reply. I was simply wondering why a certain proportion of the discussion felt alien, and I pondered as to whether this was a gender proclivity, and mused on whether tuning in to the combat mentality may be beneficial to those of us of the ‘fairer sex’ (forgive me, Jane Austen).
super interesting to think about. I have not noticed in my residents a sig. difference between males and females in terms of their outward manifestations of stress, but I obviously have no insight into their inner worlds.
I wonder how much the gender specificity of Grossman’s comments would apply to a mixed gender military, like Israel.
And how much of this gender specificity is culturally based rather than gender-attached.
Loved it. Thanks.
thanks, Michael
Read his earlier work: “On Killing”. Very powerful and disturbing.
you think there is any resus applicability or just a powerful read?
No it is more on combat ptsd ect
Michelle, perhaps you should get back onto the RAGE podcast panel?
I look forward to your first book. The pen is mightier than the sword!
I came up with TEDD Team, Equipment, Drink, Debrief. I like Chris’s better though. All in all a great podcast, first read On Combat and On killing while in the army (second one not so relevant hopefully).
Great books on acute stress and the high performance mindset.
thanks again Mitchell
4R’s Restock, Refuel, Reassess, Round on your other patients (scan for new threats)
Another point of his is that tough decision need to be made ahead of time. Instead of deciding if you should do a cric etc. plan if I have x situation, I will cric/thoracotomy…
And I like referring to ED staff as sheepdogs 🙂
v. nice
I met Lt. Col Grossman and heard him speak at a police gathering at my church a few years back. It was eye opening and amazing to hear him speak of all his personal experiences. He spoke a lot on school terrorism etc…thanks for sharing!
great to hear that he lives up to his writing in person
Scott, Great first book club…As a military and civilian flight nurse and educator, there were great insights throughout the book and podcast. I hope to intergrate them into future training. Really enjoy your podcasts during my long drives…
Here is another acronym: CODE-D
Check your team
Organize your room
Drink
Eat
Debrief
Stay safe!
As a policeman turned paramedic I am delighted to see someone in the FOAM world talking about Grossman’s work. At least from what I’ve seen in EMS, skill sets like procedural proficiency are discussed ad nauseam but mindsets are never discussed or trained. It seems like we expect people to wake up one day and spontaneously think like operators so long as we’ve shown them enough cases. Like you mentioned in the podcast, so long as you can look past the original audience I think that Grossman can teach anyone who operates in a high acuity environment quite a bit about training the mind. Thanks for bringing this to the community.
Also, to answer the question you posed to Dave Strauss ref. ‘On Killing’ I don’t recall too many points that may be applicable. It largely discusses the psychological taxes of the act of killing itself and touches on the risks to society at large of trivializing killing in media, video games, etc.
He does have a website at http://www.killology.com/ and there’s a few articles that he makes available for free. Like ‘On Killing’ they don’t seem to be very applicable but are very good reads.
thanks for that site rec
I have been useing things from the book in my work and in traing of others for years. Nice to see the book one this site as well. And also nice to hear two of my “heros” finding it as usefull as i.
thanks my friend
Like Scott, I was directed to this material by the military med/special forces folks and agree it has tremendous relevance to our procedural performance. I think it is so significant that I am starting to incorporate this formally into my airway courses. Beginning this month, we have a psychologist, Dr. Michael Asken, lecturing in my Baltimore cadaver courses. Dr. Asken has co-authored a text with Grossman (Warrior Mindset) as well as a text with an ED doc (Code Calm). We hope to connect the dots between the physiology of stress, mindset training, and specific examples and techniques pertinent to airway management in crisis. I will add this content in my other non-cadaver courses as well.
Chevalier Jackson used to refer to “training the eyes and training the hands”; we need to add “training the brain”—few of us are naturally gifted, naturally mentally armored ED/critical care docs–I strongly believe there is a verbiage and a mindset that can positively improve our practice—and it should be integrated into to our training.
This stuff is a dramatically powerful way to better prepare ED docs—and in the process I think will help with the stress (and longevity) challenges we face.
This will make Rich’s amazing airway course even better!!!
Enjoyed the podcast and On Combat is one of my favorite books. The discussion on Hick’s Law reminded me of the Law of Primacy and how hard it is to break the first thing learned, if you can even do it in some instances.
I do have a background in aviation and I am a firm believer in simulations and how well it improves actual performance. During sim sessions, hell is rained down on you from the time the door closes to the time it opens. Bells, lights and alarms are constantly going off in these sessions and you feel your sympathetic system starting to ramp up. You have to learn how to deal with it, suppress it and fall back on your training. The times I had “real” incidents outside of the sim, they became almost non events.
Unfortunately, training is an expense and with the tight budgets these days, it can be hard to accomplish. Especially when it comes to quality simulation training. Many that control the purse strings are ignorant to the benefits of simulation training and just look at the upfront costs. However, I highly recommend getting that kind of training no matter what your job function may be.
absolutely
We face a greater calleng on the sim side, however…in aviation you can recreate the cockpit, controls and through mechanical movements generate G force, turns/tilting/etc….only thing you “fake” is the projected visual images outside the plane. Our interface is the patient–and every one is different–and the simulators we use are hardly that–they are obviously fake, non-anatomic, not visually or tactile realistic enough to give you the “innoculation” or true stress that meaningful simulation should provide. I feel the solution is real tissue (cadavers or using fiberoptics)–to demystify the anatomy–and I am also trying to create much more realistic manikins, but it is the tongue which is a biomechanical wonder and very hard to recreate, along with the complexity of the mouth, epiglottis, neck/head relationships, etc. We also need to add in loud tones of a declining pulse oximeter, nurses yelling “the pulse-ox is dropping” and vomit/blood…if we’re going to create any meaningful stress.
Not to bring the comments too low, but I listened to this (great) podcast on the drive up to cover a PICU in a much smaller town and hospital than my usual shop, and 36 hours later was intubating, lining up, etc. a 3.5 kg individual with a group that doesn’t do it that often. It went great, and I credit the “battle crap” that I took before getting started. Also, spread the no-desat apneic oxygenation knowledge at least to a couple of the RTs and nurses in this neck of the woods (who raised eyebrows when I told them to leave the NC on, but seemed to be converts by the end of the intubation and discussion that went with it). Thanks for it all.
great stuff!
For most of my career I have entered into airway management with two fears (and lots of negative self-talk)…the two fears being what if I don’t get it? and “the patient is going to stop breathing and desat”….Now I go into the airway confident that epiglottoscopy will make the procedure reliable…and that NO DESAT (in all but the sickest) will prevent desaturation (or at least delay it)…its amazing how much better one performs when the pulse ox is not alarming, the nurse is not ramped up, and you have a plan of how to approach the procedure—i.e., uvula points to epiglottis, epiglottis top of larynx, bimanual–where’s the notch and posterior structures?, head elevation if needed, etc. In hindsight the negative self talk was terrible, and in addition to stopping this, I now anticipate and visualize the epiglttis before I actually see it..and I further anticipate what if…i.e. do I need bimanual, bougie, rescue devices, etc. Mindset and performance are intertwined!
Thanks Richard,
I’m about to undertake my IC-P finals in a fortnight in Australia. You’re airway stuff has been terrifically helpful in overcoming my experience with the “two fears”. Your systemic approach has resonated with me, assisting my practice. Visualisation is such a powerful tool. I’d love to get over and do one of your courses in the future. Much appreciated!
If you need an another book, try: “Tengo Sed” – a novel about an EM resident’s experience in a surgical ICU. Cheesy, but entertaining. Scott: you should recognize a fellow trainee as the model for the evil ICU attending, “Dr. Pizza.”
I’m on it
“We are currently wasting high fidelity simulation, it should purely be for stress training. Perhaps, we should create a hell week for our 2nd years”.
Dr Weingart : we have come to a stalemate with our high fidelity Sim i.e.: can’t get some folks at times to buy into the presented Sim or they just seem disinterested and only want the teaching points……….I would love to hear thoughts on how to ramp up things with “stress training”. I think my staff could utilize this and hone their Crisis Resource Management Skills. What were some of the ideas for “hell week” for your 2nd years?
By the way………..Great book and very interesting read. Very applicable to the EMS environment.
we are actually actively plotting the 1st iteration of this concept and in the coming weeks, I’ll post some ideas and resources.
Thank-you looking forward to it.
Fantastic book club on a fantastic book!
I do think the applicability is widespread. The most interesting thing is how the mind can play tricks on you. After not competing for about two years (had a little girl so not enough time to train!), I recently entered a brazilian jiu-jitsu tournament. I felt a little nervous during the day, a little more in the pre-fight warmup, and in my first round match, completely gassed out and lost, probably my saddest competitive performance. At the time it felt my opponent weighed a lot more (not really possible since we weigh in before the fight and this is weight-class based competition), and was technically much better. On reviewing the footage later though, and corroborated by other onlookers who know my style, it was clear I fought exceedingly tense and was exhausted within a minute, and in truth, my opponent (not taking anything away he clearly deserved the win!) didn’t do anything special or that I don’t usually deal with, it just seemed that way to me at the time in a stress-induced mental knot.
In resus, I recently got asked to come down and help out the ED doc for a pediatric respiratory failure (pediatrician on way) and as I headed to the elevator I could feel the butterflies too – adult cases don’t really “get me” – and I thanked my stars when the pediatrician stepped in as I was putting on gloves and was relieved. The little ones are not for me, but it would be sad to critically under perform when most needed…
I think this book should be a must-read for anyone in combat, whether against illness or other combatants!
I’ll be sure to use the 4x4x4x4x4 in a few weeks at my next competition, or if I get roped into helping out in a pediatric case!
Thanks!
Philippe
thank you so much for that story, my friend
Great post!
As the TEMS physician for several of our local teams, i was concerned on how many of our local Law Enforcement (LE) are NOT aware of this book. I have been buying copies for a lot of our team leaders and this has been the focus of a lot of my recent education. I took a lot away from the book itself about the need for critical incident debriefing in the ED more often and tried to adjust my “care for the caretaker” discussion we have after arrests, codes, and other traumas as well. the response from staff was pretty amazing.
EBOLA95
absolutely!
As a senior resident/PEM fellow I totally see the value and foresight in being aware of the physiological responses to extreme stress, and already applied the tactical breathing technique! Beauty. Thank you Scott & Cliff!
However, Lt Grossman seems to think that the medical community appreciates the important effects of sleep deprivation. I think we are aware of them, but more often than not we’re told to suck it up… and we use current EBM (i.e. meta-analysis of observational studies) as an excuse not to combat resident fatigue. http://www.thestar.com/news/gta/2014/03/26/shorter_shifts_dont_help_medical_residents_or_patients.htm
Our pilots have been mandated to rest now for 3 decades; yet we seem fight with this notion.
Scott do you let your your residents/fellows put in a Central Line or do a Pericardiocentesis on their 18th hour, when a fresher trainee is just 2 minutes away?
in EM, residents are never there more than 12 hours and usually only 8
Yes, since we moved to a shift-based schedule. But, in your ICU… how confident are you in a tired, sleepless resident to get a difficulty airway, or get a line without gettin multiple arterial stabs?
i think 24’s need to disappear in the ICU as well. Night float seems the way to go IMNHO
Great podcast, Scott… as always…
Strangely enough I’ve worked out a few rules for myself that turned out to be in the book… one of them tricking your brain into thinking not “if” rather than “when” as a trigger point… I found it so-o helpful in numerous situations when managing a critical patient it works almost like “set-and-forget” mechanism… you “set up” a crucial point and once it comes up -you already know what to do as you have already thought it through and didn’t it becomes a breeze. I also have augmented it with “prebriefing” of the staff and that makes everyone to be on the same page and so much easier and straightforward when faecal matter eventually hits the blades…
Thank you again for fast book review…
As a grad student I sometimes have to triage my reading time, and I just now got the book. Now that I’ve read it, it’s time to make another addition to my teaching packet. Another brick in the foundation of becoming an expert/master provider.
As I was reading it hit so many chords, I could have written a symphony. I was a failed special operator. When I enlisted int he Air Force I had every intention of becoming a pararescue specialist. Well i didn’t quite make it. But I did end up with what I considered the best job in the Air Force and that was taking care of Air Force Spec Ops people. Combat Controllers, Pararescue Specialist, Combat Weather men. (Yes there is such a thing.) I had the best of all worlds, I got to train with them but didn’t have to deploy somewhere in the world at a moments notice.
We trained the rescue specialist in something called the lane. It was a mix of high and low fidelity simulation, under as close to combat environments as you can come without actually shooting your students. I can remember clearly the first few times I ran the lane. It felt like the opening sequence of Saving Private Ryan. I was disconnected, non functional, I was in that Black Zone. The instructors yelled and actually threw things at me to get my attention. Once they got it, their presentation changed. They knew that adding to my stress wasn’t going to help me any. Over the next 90 days, I could pretty much handle anything they were throwing at me, and at the age of 19 I was incubation patients while hanging upside down of the side of a building with a heart rate of about 90-100, (without the aid of Beta Blockers). A little later on when I attempted my expert combat medical badge, I walked through the test and barely broke a sweat. It didn’t really hit home until a few years later I was working outside of San Francisco and a plane crashed into a mall. I clicked into that mode again just by taking a few breaths, and I was able to handle the stress and and by keeping calm I was able to help keep my coworkers calm.
When I became a civilian, there was a transition from what I could get away with as a military trainer and what I could get away with as civilian trainer. It’s still a challenge sometimes. Residents expect to be pushed by their attending, Nurses, not so much.
The one thing I disagree with you on is being able to control the rate of bagging. It is possible, But it takes a LOT of practice. One of my 1st preceptors competed in the biathlon so you can guess my initial training.
Craig you were a total badass!!