Additional Human Performance Posts by Mike

• Part I: Going with the Flow
• Part II: The Tao of Resuscitation Performance
• Part III:

In Part 1 I discussed the concept of “flow” and it’s application to the realm of resuscitation. While I believe achieving this state of optimal performance is very real and certainly possible, this concept in and of itself can appear somewhat abstract and leaves many questions. Can we actually apply different psychological tools to manage our response to stress in a medical emergency? If so, how do we achieve this?

Since the turn of the century, neurobiologists and cognitive psychologists have made substantial efforts to investigate how humans can regulate emotional responses to different stimuli. The physiological and biochemical mechanisms that underlie an individual’s response to stress are, without a doubt, complex and far from being completely understood. However, some recent evidence seems to demonstrate that aspects of mindfulness, focusing on and being aware of one’s feelings, thoughts, and sensations, as well as meditation can help cope with stress and anxiety in different circumstances (1,2,3,4,5). Furthermore, there is limited evidence that suggests mindfulness techniques are associated with increased ability to focus attention, increased speed processing visual information, and enhanced flexibility of thinking (4).

This idea, that various tools and techniques can be employed to manage stress and one’s level of arousal, is important because evidence points to critical connections between perceived difficulty, arousal, and performance. In 1908, Robert Yerkes and John Dodson presented their ground-breaking research on the non-linear nature between arousal, based on task difficulty, and brain functioning (6). Since then many have continued to explore this relationship between arousal and performance in different fields (7,8,9,10,11,12,13,14). However, only recently have we begun to explore the effects of acute stress on the performance of healthcare providers during resuscitation (15). Some of research available on the topic, although far from conclusive, seems to demonstrate similar results to what is known from other high-risk industries such as nuclear power, commercial aviation, the military, and law enforcement: performance appears to become impaired under acutely stressful conditions (16,17).

I believe that a number of tools that have been shown to help manage stress and improve performance in other venues can be adapted to the world of resuscitation. Furthermore, I propose that these tools can be integrated into a cyclical model that both allows a care provider to arrive at an optimum level of performance, by modulating their arousal, and sustain that level for the duration of the resuscitation. This cycle represents the yin and yang of resuscitation performance psychology and consists of two processes: engaging and disengaging.

Engaging is about using tools that assist you in controlling and managing your response to an acutely stressful medical emergency, allowing you to think clearly, recall important information quickly, act decisively, and perform skills efficiently. It includes tools such as tactical breathing, positive self talk, visualization exercises, using trigger words, and adjusting posture. Disengaging might allow you to sustain this level of performance over time. It applies tools that take advantage of moments throughout a resuscitation to take mini mental breaks, avoid distraction, steer clear of cognitive traps, and recover from mistakes. In future posts I will dive into the evidence behind these techniques as well as my perception of their practical application to the world of emergency medicine and critical care.

References

1. Shapiro et al. “Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial.” Int J Stress Management 2005; 12(2): 164–176.
2. Niazi & Niazi. “Mindfulness-based stress reduction: a non-pharmacological approach for chronic illnesses.” N Am J Med Sci 2011; 3(1): 20–23.
3. HeidariGorji et al. “The efficacy of relaxation training on stress, anxiety, and pain perception in hemodialysis patients.” Indian J Nephrol 2014; 24(6): 356–361.
4. “Spirituality and the Aging Brain.” Generations 2011; 35(2): 83.
5. Shapiro et al. “Effects of Mindfulness-Based Stress Reduction on Medical and Premedical Students.” J Behav Med 1998; 21(6): 581–599.
6. Yerkes & Dodson. “The relation of strength of stimulus to rapidity of habit-formation.” J Comp Neurol Psychol 1908;18:459–482.
7. “Cognitive, Endocrine and Mechanistic Perspectives on Non-Linear Relationships Between Arousal and Brain Function.” Nonlinearity Biol Toxicol Med 2005; 3(1): 1–7.
8. Lupien et al. “The effects of stress and stress hormones on human cognition: Implications for the field of brain and cognition.” Brain Cogn 2007; 65(3): 209–237.
9. Fiore & Salas. “Cognition, competition, and coordination: The “why” and the “how” of the relevance of the sports sciences to learning and performance in the military.” Military Psychology 2008; 20(Suppl 1), S1–S9.
10. On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. Warrior Science Publ; 2008.
11. Siddle. Sharpening the Warrior’s Edge. PPCT Management Systems; 1995.
12. Asken & Grossman. Warrior Mindset: Mental Toughness Skills for a Nation’s Peacekeepers. Human Factor Research Group; 2010.
13. The Gift of Fear: Survival Signals That Protect Us from Violence. Bloomsbury; 2000.
14. Deep Survival: Who Lives, Who Dies, and Why. W. W. Norton & Company; 2004.
15. “The Effects of Acute Stress on Performance: Implications for Health Professions Education.” Academic Medicine 2009; 84(Supplement), S25–S33.
16. LeBlanc et al. “Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator.” Prehospital Emergency Care 2005; 9(4), 439–444.
17. Cumming & Harris. “The impact of anxiety on the accuracy of diagnostic decision-making.” Stress and Health 2001 17(5), 281–286.

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Mike Lauria

Regular Contributor at EMCrit.org

Emergency Medicine Resident
University of New Mexico Health Sciences Center
Former US Air Force Pararescue and Critical Care/Flight Paramedic

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