Editor's Note 6/4/20: In the wake of the devastating incidents of police violence, many with racially biased overtones, the kill or be killed attitude endorsed by Dr. Grossman has justifiably come under fire. A few folks have asked (some, not so nicely) that this episode be taken down. While we sharply disagree with that aspect of Dr. Grossman's work, none of those aspects are discussed in this podcast. We feel it would be a loss to the resus community to take down this episode. Instead, please separate the things discussed here from other problematic facets of his recommendations.
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
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
- 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