To plan maneuvers so that some of the elements of frication are involved…is far more worthwhile than inexperienced people might think. It is immensely important that no solider…should wait for war to expose him to those aspects of active service that amaze and confuse him when he first comes across them. If he has met them even once before, they will begin to be familiar to him. – General Carl von Clausewitz, Vom Kriege (On War) ¹

In EMCrit Podcast 164 Mike Mallin tells the harrowing tale of “The Day I Didn’t Use Ultrasound.” The lecture given at Blood and Sand 2015, by all accounts, was amazing. I have only been able to listen the recording, but I wish I could have been there to see and hear it live. If you haven’t heard it yet, stop right now and go listen.

There’s really no way that I could spoil such an amazing talk, but I’ll try not give too much away. In the talk Mike mentions the importance of preparing for taxing and stressful events. He specifically mentioned the importance of Stress Inoculation Training (SIT). This continues to be a hot topic in critical care and emergency medicine, in the hospital as well as the prehospital environment. In fact, there was an entire preconference workshop at SMACC dedicated to this very topic with Chris Hicks (@HumanFact0rz), Anand Swaminathan (@EMSwami), Jesse Spurr (@Inject_Orange), Chris Nickson (@precordialthump), and Jason Brooks (@phenomenaldocs). If you haven’t signed up for a preconference workshop this year at SMACC Dublin, check this one out.

I wanted to take this opportunity to review what SIT is, how it works, and what the evidence is to support it. The neurobiology of stress and arousal, specifically the physiological effects on cognition and skills performance, have been discussed previously.² So, I will bypass that discussion and cut to chase. If that interests you, check out previous posts here or some of the references listed at the end of the post. For now, let’s talk inoculation…

Preparing to Face the Heat

Jumping out of a perfectly good aircraft is stressful. Jumping out of a perfectly good aircraft in the middle of the night, in the middle of nowhere is very stressful. In fact, “jumping” is really a misnomer. With more than 130 lbs of equipment attached to you, you don’t really jump. You just kind of…well…fall. And, oh, by the way, the fact that someone’s life hangs in the balance 10,000 feet below you ups the ante a little bit. This, however, is the job that we signed up to do as Pararescuemen (PJs).

Knowing that we were human and would inevitably experience the deleterious effects of stress at times such as these drove us to train. We prepared by systematically exposing ourselves to very stressful situations. We basked in the catecholamine rush. It was important because we learned how our bodies reacted, witnessed how our decision making changed, and got a preview of potential pitfalls. We trained to 130% so that when our faculties deteriorated under stress, we could still function at 100%. Over time, we each developed skills to work with our natural physiological response, manage it, and even use it to our advantage.

Working in the ICU, the ED, or prehospital environment as a resuscitationist is, I will concede, somewhat different than military freefall parachuting. However, I contend that two key principles remain: 1) You will experience stress and it’s negative effects taking care of critically ill or injured patients and 2) preparation is required to perform at your very best.

This post is about how to prepare you and your colleagues.

Inoculation to Manage the Effects of Stress

Stress Inoculation Training (SIT) is a multifaceted type of cognitive-behavioral therapy designed to help individuals cope with stress. It was initially developed by psychologist Donald Meichenbaum in the 1980s and has been employed to mitigate the sequelae of stress in a variety of situations. The essence of SIT is that by exposing people to increasing levels of perceived stress, they practice employing different coping skills and eventually develop increased tolerance or immunity to a particular stimulus. ³

The training consists of three phases that are designed to empower individuals and enhance their repertoire of coping skills^4,5,6:

1. Conceptualization – This phase is designed to achieve two specific goals. First, it builds a relationship between the therapist, coach, or trainer. Second, it educates an individual, increasing their understanding and awareness of his or her stress response and existing coping skils. According to Meichenbaum, is it peferential for this phase to be less didactic and more Socratic in nature. He suggests using “curious questions” to promote an individuals processing and discovery.
2. Skills Acquisition and Consolidation – This phase is all about developing and practicing individual psychological tools and cognitive restructuring techniques (breathing techniques, relaxation techniques, negative thought stopping, etc.). The goal is build the coping techniques to they can be applied in the next phase to regulate negative emotions and increase control over physiological responses. They are discovered, nurtured, and strengthened in collaborative manner with a trainer or therapist.
3. Application and Follow-through – This phase is, in essence, the phase of inoculation. On a graduated basis, an individual is exposed to increasing levels of a particular stressor and practices applying the skills they have developed to mitigate his or her stress response.

Modifications of Stress Inoculation Training: Stress Exposure Training

It is important to recognize that Meichenbaum’s intention was really to help individuals cope with physical pain, anxiety, anger, and fear as a result of traumatic experiences. This was a clinical intervention designed to treat pathological psychiatric conditions. However, various organizations and individuals saw the potential benefit of instituting this technique prophylactically. Organizations, like the military and NASA, began to adapt the traditional structure of SIT in demonstrated substantial improvements in performance.^{7,8,9,10,11,12}

One adaptation of SIT is Stress Exposure Training (SET). SET, originally proposed by Driskell and Johnston, takes a slightly different approach.¹¹ Its general structure is similar to Meichenbaum’s cognitive behavioral approach. It is dived into three analogous phases:

1. Information provision – This phase provides information on the human stress response, conditions participants should expect to encounter, and other preparatory information
2. Skills acquisition – This is phase is designed to develop and refine behavioral, technical, and cognitive skills
3. Application and practice – This phase includes practicing skills under conditions that approximate the operational environment and that gradually attain the level of stress expected

SET is different in that, quite simply, it takes a proactive approach. It provides prophylaxis. It prepares individuals without psychiatric pathology for potential stressors and situations that are likely to encounter.

I’ll make a point to emphasize that whether we call it Stress Inoculation or Stress Exposure, makes little difference. Truth be told, I prefer the term “inoculation.” However, the important thing is that we maintain the salient training objectives and strategies as they have been developed for SET. The goals of exposure training are as follows^12,13:

#1 to gain knowledge and familiarity with a stressful environment

#2 to develop and practice task-specific skills (including various psychological skills), as well as decision making faculties, to be performed under stress

#3 to build confidence in an individual’s capabilities

Lessons from the Pool: How SET Works and Why Each Phase Is Important¹²

Part of Pararescue training was called “Drown-proofing.”  It wasn't the most fun method to develop confidence in the water, but it worked.  The exercise entailed tying our hands (behind your back) and our feet together, then jumping into a 15 foot deep pool.  We were then expected to perform various tasks like bobing up and down off the bottom of the bool, traveling 100 meters distance on the surface, recovering items off the bottom of pool with your teeth, or doing somersaults underwater.  This exercise had some survival, situation specific applications.  But, more importantly, it was a cheap and effective way to train people how to manage their physiological response to a profound stressor: not being able to breath.

Phase 1 – Information Provision

Before we even approached the edge of the water, our instructors told us what to expect.  They said it was normal to be anxious; it was normal to be uncomfortable with your hands and legs tied together.  Furthermore, it was a normal physiologic response to experience an elevated heart rate, physical discomfort, and a general unease having to hold our breath.  They also explained why it would be important to relax and reduce our bodies' oxygen consumption as much as possible.

In the first phase, preparatory information is provided to trainees. They are taught about the physiological response to stress normally and how these natural physiological mechanisms can interfere with the specific cognitive processes and technical skills during resuscitation. It ensures that everyone understands this deterioration in their faculties is normal. Furthermore, it generates accurate predictions of how they will respond. As it turns out, this is critical. Just by having more precise expectations, people perform better under stress.¹⁴

Another important part of this phase is making it clear that providers aren’t helpless in the face of this hard-wired response. The belief that people have the capacity to exert control over their behavior is critical. This understanding of self-efficacy has been linked to improved performance in different domains.^15,16 It also allows you to predict potential areas of weakness and motivate individuals to obtain the necessary skills to improve their response under stress.^17,18

Phase 2 – Skills acquisition

We practiced drown-proofing every day for months.  Everybody developed tricks and methods to help keep calm, manage their anxiety, and prepare to address various challenges that arose during the exercise.  Some people developed a mantra they would repeat to themselves to build confidence.  Others sung songs in their heads to calm them down.  Still others practiced muscle relaxation techniques whenever possible under water.

The crux of Phase 2 is to develop the host of technical and non-technical skills needed to perform in the resuscitation environment without the addition of stressful stimuli. The goal is to learn and develop constructive coping mechanisms and to develop effective performance habits. The fundamental technical skills of emergency medical care must be established in conjunction with various cognitive and behavioral techniques. Precisely what medical skills need to be acquired and how they are to be taught depends on an individual’s role and level of experience. I will leave these recommendations to experts in the field of emergency medicine and critical care.

As far as the cognitive and behavioral skills go, I will attempt to outline some key techniques. I would hasten to add that these, too, need to be adapted to different settings. Also, at least in my opinion, they need to be individualized. Some people have an easier time with certain techniques than others. That’s fine. Develop a habit of using the various psychological tools that work best for you. It is also worth pointing out that I developed the concepts of Performance Enhancing Psychological Skills (PEPS) and also the components of “Beat The Stress Fool” or BTSF (for more on this check out the post on Enhancing Human Performance in Resuscitation) from the following list of evidence-based techniques:

Cognitive Control Techniques

The foundation of evidenced-based cognitive behavioral therapy in psychiatry is the fact that there is fundamental connection between what a person thinks, what they feel, and how they act. Cognitive control techniques are designed to provide control over distracting or stress-inducing thoughts. At it’s core, this is essentially a metacognitive process. The individual is taught to recognize deleterious or distracting thought processes and stopping them. The negative thoughts are replaced with positive, task-focused thoughts.

Say, for example, that a patient presents to you in respiratory failure. At first glance, just based on preliminary information you immediately think “Oh crap! That looks like a difficult airway. I haven’t had one of these in a while.” You feel your heart rate start to increase and you start to experience feelings of doubt or anxiety. A cognitive control strategy might be to tell yourself… “It might be difficult, but I can take care of this. I have been trained to manage difficult airways and I have managed them before. I know the various steps I can take to optimize oxygenation and maximize my chance of first pass success. I have a great team to support me. I can do this.” You could even make it even more specific. It could, perhaps, be made even more task specific by including individual steps. Regarding patient preoxygenation, you could invoke the words of airway master, Dr. Richard Levitan, and say “Sit the patient up, jaw forward, O’s through the nose.” These thoughts or self-suggestions are positive, self-affirming, and task specific. They not only use thoughts to change emotional condition (decrease fear or anxiety),¹⁹ but they also hone attention on the task at hand. Both are important aspects of dealing with stress and improving performance in this situation.^20,21

Physiological Control Techniques

These strategies are aimed at controlling specific physiological parameters. Certain physiological responses, such as tachycardia and hyperventilation, magnify the effects of anxiety and contribute to the unfavorable effects of stress on fine motor control, visual acuity, and cognition. Some effective techniques include progressive relaxation or biofeedback.^22,23 However, these techniques are not always feasible when suddenly presented with a decompensating patient. One method that shows great promise and could easily be applied in resuscitation is controlled breathing. Different techniques of breathing have been used in diverse fields: from yoga, meditation, and martial arts to public speaking and athletics. (For a more complete discussion of breathing, including references, check this out)

Mental Practice and Rehearsal

Mental practice is defined as the cognitive rehearsal of a task in the absence of overt physical movement and was initially explained by Richardson in 1967.²⁴ From a neurophysiolocal standpoint, visualizing a procedure, task, or scenario can serve as a practice run before actually performing the procedure. In fact, “the same neural pathways are recruited and the same neurochemicals are secreted when we visualize doing something as when we engage in the actual activity.”²⁵ Mental rehearsal has been investigated extensively in the sports and performance psychology literature and shows benefit.^25,26,27,28 Techniques of mental practice have also demonstrated improvements in performance of surgical skills.^29,30 Most recently, Gianni Lorello, Chris Hicks (@HumanFact0rz), and a team from the University of Toronto in Ontario demonstrated the effectiveness of using mental practice to prepare teams for trauma resuscitation.³¹

Other important aspects of Phase 2

There are several other important aspects to Phase 2 that authors have established.¹² Some of these include training decision-making skills (e.g. institution specific airway algorithms or checklists), overlearning technical skills (e.g. central venous access, laryngoscopy, or chest tube insertion), communication, and team training. These specifics will not be discussed in detail here. When it comes to these specific training methods, I will defer to the expert clinician educators and/or currently established institutional training.

Phase 3 – Application and Practice

When we had the basics down, the instructors began to raise the bar.  We started out performing the exercise in swim wear, but by the end of training we were forced to do it fully dressed in uniform.  Additional environmental stressors were added including complete dark, loud music, and physical obstacles to swim around, over, and under.

The application and practice phase is designed to take the skills learned in Phase 2 and rehearse them under increasingly stressful conditions. This allows trainees to experience, in real-time simulation, the various performance challenges they will face in a specific (OR, ED, or prehospital) setting. It also reduces uncertainty and anxiety as well as increases confidence when individuals realize that they can overcome stressors. Finally, stimuli experienced during stress training are less distracting when experienced in real life.   Requisite to these desired effects is a graduated approach to stress exposure. It is by incrementally increasing the stress that the desirable outcomes of familiarity, resilience, and confidence, are developed. ^12,17

The biggest mistake in emergency skills training programs is that they sometimes emphasize this phase of training exclusively. I often see programs, in the military and civilian world, that throw trainees into stressful situations, without preparatory information or effective skills development, hoping to reap the benefits of “stress training.” If your goal is to select people with a more instinctive and natural ability to manage stress, this may be effective. However, if your intention is to develop an already intelligent, thoughtful, and well-meaning group of individuals into top performers, this will not work. Furthermore, it carries the risk of leaving trainees confused, frustrated, and anxious about confronting these situations in simulation as well as the real world. The training is cumulative. The first two phases are equally as important as the last.

It’s also worth mentioning at this point that there is some disagreement in the literature over whether stress facilitates or inhibits effective learning.^{12,33,34,35,36}  However, my interpretation of the available literature is that this depends on the level of experience of the learner, the degree to which the learner has already established effective technical and non-technical skills, and the whether the learner comes away from the training event with increased confidence. By its very nature, SET takes advantage of both approaches. The skills are established in Phase 2 (without stress) and then practiced, tempered, and refined under increasing amounts of stress in Phase 3.

Limitations to Applying Stress Exposure Training in Medicine

Despite recent attempts to demonstrate the effectiveness of training under stressful conditions, there has not yet been an RCT demonstrating the effectiveness of a comprehensive SET program in medicine. Some attempts are currently underway. However, based on the results enjoyed in a other high-risk occupations, I believe it is reasonable and prudent to continue to study SET in the setting of emergency medicine and critical care.

Important Take-Home Points…

1. Stress is an incontestable aspect of resuscitation. Virtually every study published on the topic demonstrates that performance diminishes under stress.
2. Technical skill and knowledge are absolutely necessary, but not entirely sufficient to perform effectively in stressful situations.
3. To ensure consistency with the literature, it is prudent to point out the Stress Inoculation Training (SIT) refers to a form of cognitive behavioral therapy used in psychology. When these concepts are applied in a prophylactic manner to improve performance, it is generally referred to as Stress Exposure Training (SET).
4. There are three phases to SET: information provision, skills acquisition, and application and practice.
5. Most people erroneous believe that “stress training” is really just about exposing trainees to stressful conditions in simulation or otherwise. In fact, the first two phases are equally important.
6. The focus of SET should be on developing and practicing psychological skills and behaviors that allow individuals to function optimally under stress.
7. When applying and practicing these skills, every attempt should be made to recreate operational conditions as best as possible. However, 100% fidelity is not necessary to derive the beneficial effects of the training
8. Stress exposure training can be effectively integrated as part of both initial and refresher training.
9. To date, there has not been a single report of psychological sequelae as a result of this training.
10. There has not yet been an RCT completed that has examined the benefits of SET, as explained here, in resuscitation. There are, however, some currently underway. Further investigation is necessary to adequately demonstrate the effectiveness in the realm of emergency medicine and critical care.

For a more in-depth discussion with commentary by an experienced EM physician, check out this podcast on Stress Inoculation Training on iTeachEM with Anand Swaminathan.

Great books on training for stressful environments…

References

1. Clausewitz, C. von. (1984) On war (M. Howard & P. Paret, Trans.). Princeton, NJ: Princeton University Press.
2. Staal, M. A. (2004). Stress, cognition, and human performance: A literature review and conceptual framework. NASA technical memorandum, 212824, 9.
3. Meichenbaum, D. (1976). A self-instructional approach to stress management: A proposal for stress inoculation training. In C. Spielberger & I. Sarason (Eds.), Stress and anxiety in modern life. New York: Winston.
4. Meichenbaum, D., & Cameron, R. (1989). Stress Inoculation Training. In D. Meichenbaum & M. E. Jaremko (Eds.), Stress Reduction and Prevention (pp. 115–154). Springer US.
5. Meichenbaum, D. (2007). Stress inoculation training: A preventative and treatment approach. Principles and practice of stress management, 3, 497-518.
6. Keinan, G. & Friedland, N. (1996) Training effective performance under stress: Queries, dilemmas, and possible solutions. In JE Driskell & E. Salas (Eds.), Stress and Human Performance. Mahwah, NJ: Lawrence Erlbaum Associates.
7. Johnston J.H. & Cannon-Bowers J.A. (1996). Training for stress exposure. In J.E. Driskell & E. Salas (Eds.) Stress and Human Performance. Mahwah, NJ: Lawrence Erlbaum Associates.
8. Driskell, J. E., Johnston, J. H., & Salas, E. (2001). Does stress training generalize to novel settings? Human Factors, 43(1), 99–110.
9. Saunders, T., Driskell, J. E., Johnston, J. H., & Salas, E. (1996). The effect of stress inoculation training on anxiety and performance. Journal of Occupational Health Psychology, 1(2), 170–186. http://doi.org/10.1037/1076-8998.1.2.170
10. Gaab, J., Blättler, N., Menzi, T., Pabst, B., Stoyer, S., & Ehlert, U. (2003). Randomized controlled evaluation of the effects of cognitive–behavioral stress management on cortisol responses to acute stress in healthy subjects. Psychoneuroendocrinology, 28(6), 767-779.
11. Gaab, J. 1., Sonderegger, L., Scherrer, S., & Ehlert, U. (2006). Psychoneuroendocrine effects of cognitive-behavioral stress management in a naturalistic setting—a randomized controlled trial. Psychoneuroendocrinology, 31(4), 428-438.
12. Driskell, J. E., & Johnston, J. H. (1998). Stress exposure training. In J. A. Cannon-Bowers & E. Salas (Eds.), Making decisions under stress: Implications for individual and team training (pp. 191–217). Washington, DC, US: American Psychological Association.
13. Driskell, J. E., Salas, E., Johnston, J. H., & Wollert, T. N. (2008). Stress exposure training: An event-based approach. Performance under stress, 271-286.
14. Druckman, D., & Swets, J. (1988). Enhancing Human Performance:: Issues, Theories, and Techniques. Washington, D.C.: National Academies Press.
15. Bandura, A., Reese, L., & Adams, N. E. (1982). Microanalysis of action and fear arousal as a function of differential levels of perceived self-efficacy. Journal of Personality and Social Psychology, 43(1), 5–21.
16. Locke, E. A., Frederick, E., Lee, C., & Bobko, P. (1984). Effect of self-efficacy, goals, and task strategies on task performance. Journal of Applied Psychology, 69(2), 241–251. http://doi.org/10.1037/0021-9010.69.2.241
17. Keinan, G., & Friedland, N. (1996). Training effective performance under stress: Queries, dilemmas, and possible solutions. In J. E. Driskell & E. Salas (Eds.), Stress and human performance. Mahwah, NJ: Lawrence Erlbaum Associates. 257-277.
18. Thompson, S. C. (1981). Will it hurt less if I can control it? A complex answer to a simple question. Psychological Bulletin, 90(1), 89–101.
19. Wine, J. D. (1980). Cognitive-attentional theory of text anxiety. In I. G. Sarason (Ed.) Test anxiety: Theory, research, and applications. Hillsdale, NJ: Lawrence Erlbaum Associates. 349-385.
20. Wine, J. (1971). Test anxiety and direction of attention. Psychological Bulletin, 76(2), 92–104.
21. Singer, R. N., Cauraugh, J. H., Murphy, M., Chen, D., & Lidor, R. (1991). Attentional Control, Distractors, and Motor Performance. Human Performance, 4(1), 55–69.
22. Burish, T. G., Carey, M. P., Krozely, M. G., & Anthony, F. (1987). Conditioned side effects induced by cancer chemotherapy: Prevention through behavioral treatment. Journal of Consulting and Clinical Psychology, 55(1), 42–48. http://doi.org/10.1037/0022-006X.55.1.42
23. Dobie, T. G., May, J. G., Fischer, W. D., Elder, S. T., & Kubitz, K. A. (1987). A comparison of two methods of training resistance to visually-induced motion sickness. Aviation, Space, and Environmental Medicine, 58(9 Pt 2), A34–41.
24. Richardson, A. Mental Imagery. London: Routledge & Kegan Paul; 1969.
25. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business; 2015.
26. Martin KA, Moritz SE, Hall CR. Imagery use in sport: A literature review and applied model. The Sport Psychologist. 1999;13(3):245-268.
27. Feltz DL, Landers DM. The effects of mental practice on motor skill learning and performance: A meta-analysis. Journal of Sport Psychology. 1983;5(1):25-57.
28. Weinberg R. Does imagery work? Effects on performance and mental skills. Journal of Imagery Research in Sport and Physical Activity. 2008;3(1).
29. Hall JC. Imagery practice and the development of surgical skills. Am J Surg. 2002;184(5):465-470.
30. Arora S, Aggarwal R, Sirimanna P, et al. Mental practice enhances surgical technical skills: a randomized controlled study. Ann Surg. 2011;253(2):265-270.
31. Lorello, G. R., Hicks, C. M., Ahmed, S.-A., Unger, Z., Chandra, D., & Hayter, M. A. (2015). Mental practice: a simple tool to enhance team-based trauma resuscitation. Canadian Journal of Emergency Medicine, FirstView, 1–7.
32. LeBlanc, V. R. (2009). The effects of acute stress on performance: implications for health professions education. Academic Medicine, 84(10), S25-S33.
33. Sandi, C., & Pinelo-Nava, M. T. (2007). Stress and Memory: Behavioral Effects and Neurobiological Mechanisms. Neural Plasticity, 2007. http://doi.org/10.1155/2007/78970
34. Roozendaal, B. (2002). Stress and memory: opposing effects of glucocorticoids on memory consolidation and memory retrieval. Neurobiology of Learning and Memory, 78(3), 578–595.
35. Roozendaal, B. (2002). Stress and memory: opposing effects of glucocorticoids on memory consolidation and memory retrieval. Neurobiology of Learning and Memory, 78(3), 578–595
36. DeMaria Jr, S., Bryson, E. O., Mooney, T. J., Silverstein, J. H., Reich, D. L., Bodian, C., & Levine, A. I. (2010). Adding emotional stressors to training in simulated cardiopulmonary arrest enhances participant performance. Medical education, 44(10), 1006-1015.

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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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