Now the way of life that I preach is a habit to be acquired gradually by long and steady repetition. It is the practice of living for the day only, and for the day’s work… -Sir William Osler

In Situation Awareness in Resuscitation (Part 1), I discussed the cognitive science behind situation awareness (SA) and how it has become a part of evaluating non-technical skills in different specialties (namely emergency medicine, surgery, and anesthesia).  In this post I will discuss some ideas for improving SA in resuscitation.

Active Systems of Situation Awareness

People often underestimate the complexity of a fundamental air rescue skill: scanning. The technique of searching for objects or people from an aircraft may seems simple. It is, in fact, somewhat more nuanced. Whether you’re flying in an aircraft in a combat zone, searching in the mountains for injured climbers, or monitoring a sick patient in flight, scanning is actually a skill. It seems so strait forward: just look around at the ground or just watch the patient…right? It couldn’t be any simpler. All you have to do is watch and pay attention. But, we know that whether you are searching a mountain side or watching the monitor of a patient under anesthesia that this is easier said than done.^1,2

In fact, it’s much harder to continually scan and maintain situation awareness at extremes of the activity spectrum. When many things are happening concurrently is difficulty to maintain global and local situational awareness. On the other hand, when things become mundane or reach some kind of steady state, one can become lulled into a false sense of stability and lose SA. Our mind and our eyes wander. We get distracted thinking about other things.   Even when things are dynamic and changing rapidly, it’s sometimes hard to keep an eye out and detect subtle, and sometimes even overt, indications that something is about to go wrong.

One solution to the problem used in the rescue world is to train people to use an active, systematic scanning pattern. There are a number of scanning techniques that can be used, but they share similar characteristics. One technique rescuers learn is to start scanning about 10^o – 20^o below the horizon (approximately one finger’s width below the horizon) and allow the eyes to move from one point of fixation to another point of fixation along a line extending from the point on the horizon back to the aircraft. The points of fixation are generally 3-4 finger widths apart, allowing for overlapping fields of central vision. (There is a surprising amount of science behind visual processing and how it relates to the brain’s ability to perceive and comprehend information, both keys to SA. For an in-depth discussion of scanning check out Chapter 5 in the Aviation Emergency Services Aircrew Training Reference Text.)³

In Situation Awareness in Resuscitation (Part 1), I opened with a discussion about a high-risk rescue modality were SA is also imperative: hoisting. One of the way to mitigate risk during hoist operations is training people to adopt a scanning system. An active system of awarness is developed that quickly becomes habitual:

1. Look up at the flight engineer (or pilot or whichever individual is in charge of controlling the ascent or descent of the hoist cable)
2. Trace the cable from the aircraft down to your harness
3. Scan your harness and connecting devices
4. Scan the patient or equipment in front of you it’s securing system
5. Look around you and below you at the ground (if you have a person on the ground assisting with the hoist via tagline to the patient, you would scan down the line to them.

Similar techniques are applied to communication. Many people are familiar with the concept of closed-loop communication and this operates under similar principles. Another example from the world of air rescue is exchange between pilots and other aircrew. As the aircraft approaches to insert personnel via rope, hoist, or simply landing on the ground, there is a very specific discourse that creates an active “circle of awareness.” The pilot at the controls is focused on the terrain, instruments, and flying the aircraft. The other crewmembers are scanning around the aircraft in all directions. As the pilot approaches the target he might call, “50 and 50”, signaling that he has descended to 50 feet and 50 knots. You then hear the crew members clearing their zones of responsibility: “clear left”, “clear right”, “clear back.” The crew members don’t just look and call out if there is a problem. In this dynamic phase of flight, everyone quickly acknowledges that their zone is clear with an affirmative response. If there is a lapse in this circle of awareness everyone is immediately aware of a break in the communication loop and it automatically leads them to question what is going on. In addition, it keeps the locus of your attention focused on a particular area or object. You know that you are expected to provide and active response and are, therefore, significantly more likely to pay attention to scanning your area.²

An example of this in resuscitation would be team SA during rapid sequence intubation. One team member, the individual placing the endotracheal tube is clearly dedicating 100% of their awareness to what is going on locally, in the vicinity of the oropharynx and glottis. However, another teammate can be assigned to maintain global situational awareness. Retrieval teams generally operate in teams of two. Thus, the partner not placing the airway often is in charge of administering medications. After the medications are administers they constantly scan the area: the monitor, the patient, the surrounds, and back to their partner. They are in charge actively looking at each of these domains and looking for problems or potential issues. These may be as simple as identifying that the PEEP valve fell off the BVM or as important as a precipitous drop in blood pressure or oxygen saturation.

These behaviors can be taught and developed. You can train people to develop active systems of awareness in certain situations that will allow them to identify a baseline of how things should be and then notice when things go wrong. Instead of waiting until your attention is brought to a problem by an alarm or flashing light, you are actively checking these systems. You are constantly looking for even small changes or perturbations of the system that could signal problems on the horizon.

Habits are powerful, but delicate. They can emerge outside our consciousness, or can be deliberately designed. They often occur without our permission, but can be reshaped by fiddling with their parts. They shape our lives far more than we realize—they are so strong, in fact, that they cause our brains to cling to them at the exclusion of all else, including common sense. – Charles Duhigg

A Force of Habit

Developing a behavior is helpful, but converting that behavior into a habit is powerful.

Think about the habits in your everyday life that streamline cognitive processes and help you get through your day (or, conversely, the lack of effective habits that may cause problems). What you do when you get up in the morning? What is the first things you do when you get to work? Where do you drop your car keys when you get home? What about your routine and habits prior to going to bed at night? In terms of resuscitation, it likely that experienced practitioners have high fidelity motor programs (i.e. some habits) that they carry out even in the face of a crashing patient.   A provider might identify a patient who is experiencing imminent respiratory failure, call for help, begin basic supportive measures, and immediately set up their intubation equipment. Often, the precise equipment set up is the same way they’ve done it shift after shift for years. He or she doesn’t even have to think about the set up unless something in the scenario is different or novel. Other practices, such as using a preinduction checklist, might be part of his or her routine as well. They just do it. It’s habit.

In fact, habits can be more powerful than willpower. They can, in some instances, over-ride conscious analytical mechanisms and distractions. This can be both detrimental and beneficial depending on the situation. As many people understand from life experience, developing healthy habit can be very difficult. Yet, one a good habit is established it can become highly effective. Clinically, we see on a daily basis the devastating effects of substance abuse and addiction. However, we also see the evolution of effective habits that engender patient safety: confirming medications before administration or running patient checklists in the OR before a procedure starts.

In his book, The Power of Habit, Charles Duhigg provides an excellent explanation how habits work.⁴ Although, at the molecular, level the precise mechanism of habit formation is not entirely understood, a general model from a neurological and behavioral standpoint is understood. Humans operate what Duhigg calls “habit loops.” First, there is a cue that triggers your brain to access a deeply imprinted thought, feeling, or pattern of behavior. Next, a particular routine is executed. This is what we colloquially refer to as the “habit”. Finally, there is some reward from the routine: a feeling of comfort, the chemically stimulated sensation of pleasure, or positive feedback in the form of high performance.

One of the reasons that habits are such robust behavioral patterns is because their existence, once established, doesn’t seem to be reliant on consciousness. Research from MIT indicates that the locus for habitual behaviors may be primarily operant in the more primitive areas of the brain such as the basal ganglia, an area vital for integration and execution of motor activity.^5,6,7 Their research suggests that when a behavior transitions to a habit,  less neuronal activity is required in the basal ganglia to generate the same motor pattern. Therefore, a presented cue seems to trigger an action that is more efficient, virtually automatic, and requires less neurochemical activity to coordinate.

Capturing the awesome power of this cycle and transforming active loops of awareness into deeply engrained automatic process may be an important piece of the SA puzzle. Developing a cue that triggers a behavior or mental process that constantly and actively evaluates a situation would enhance SA and provide an effective cognitive early warning system. Furthermore, it may be particularly desirable because consciously trying to maintain situational awareness is difficult during a chaotic and stressful resuscitation. An ingrained habit that requires less cognitive bandwidth might withstand the onslaught of information, visual stimuli, and auditory inputs.

Building a habit can be challenging, but research from the world of behavioral science holds some insight into how we can develop them for implementation in resuscitation:

1. Tie the SA promoting behavior to a trigger that is virtually inescapable

Habits are developed more effectively when they are tied to events that one simply cannot bypass.⁸ For example, a common practice in many operating rooms is to run a safety checklist before the surgery begins. The first incision is a good trigger because it's required to move forward with the procedure. In the example earlier about RSI, pushing the medications is an essential part of the procedure. In the world of prehospital medicine, you have to load the patient in a vehicle to get them to definitive care. These would both be good things to trigger a routine behavior. It’s also good because our mind tends to correlate key events in any situation. Often, neuroscientists and cognitive scientist refer to this as “chunking”.⁹ Our brains tend to link different events or situations with different behaviors. So, inevitable situations work well to connect to new behaviors.

2. Make the routine very specific

Many people in academics, business, and medicine have all probably endured annual performance review where they are asked to set “SMART Goals” for next year. The idea is that by making an objective or goal specific, measurable, attainable, results-based, and time-bound we are more likely to attain said goal. Despite these annual reviews often being the bane of our yearly professional obligations, there is a substantial amount of evidence in the psychological literature that supports this concept.¹⁰

The same is true of a habit. If you are trying to ingrain a habit, the actual routine you want someone to perform when the trigger is met must be very specific. Precision in what you want to do is critical to development of what psychologists call an implementation intention, the purposeful connection between a trigger and a routine.^11,12  Ambiguity, on the other hand, is one of the greatest enemies of habit development.¹³  In a meta-analysis of 94 studies that included 8,166 participants, Gollwizter et al found that ability for goals to be successfully translated into behaviors significantly improved when people used very specific if-then statements.¹⁴  

This might be one of the main reasons that teaching people about SA has been such a failure to date.  Just telling people to “be aware of what's going on around you” is about as nebulous as it gets.  By not offering specific cues, skills, or routines to execute, we've failed to offer a successful solution to this human factors challenge.

So, if we want someone to execute a behavior that facilitates active SA, we have to make things specific. For example, if you hear the “low pressure” alarm on the ventilator, then you should immediately check the vent-tubing connection, trace the tubing to the ET tube, etc. Another example might be, as soon as you are done pushing the RSI drugs, look at the monitor (check SpO2, heart rate, blood pressure), then the patient, then your partner (individual placing the airway), then quickly scan your surroundings (bystanders, trained medical staff assisting, look for environmental safety concerns) .

3. Rinse, dry, repeat, repeat, repeat…

Not surprising, one of the key aspects of developing an effective SA behavior is repetition. As we repeat and action that neural pathway becomes stronger and, thus, closer to being completely automatic. It’s unclear exact how many repetitions are required in a given individual for a particular task. But the literature on the subject is interesting and somewhat instructive.

The number 21 has become popular in many circles following publication of Dr. Maxwell Maltz’s ground-breaking book Psycho-Cybernetics in 1960. In the book, Maltz noted that aputees required and average of 21 days to become accommodated (physically and psychologically) to the loss of their limb. From this data, Dr. Maltz hypothesized that it takes approximately 21 days to adapt to major life changes.¹⁵ In a more recent investigation at University College London, researchers followed 96 subjects in a prospective cohort study that analyzed how long it people to make a variety of different health-related behaviors. On average it took people 66 days to make these behavior automatic. However, the range was quite broad: 18 up to 254 days.¹⁶  Of note, the simplier the habit (e.g. drinking a glass of water after breakfast) the quicker it took to make the habit automatic.

Lally P, van Jaarsveld CHM, Potts HWW, Wardle J. How Are Habits Formed: Modeling Habit Formation in the Real World. Euro J Soc Psych. 2010; 40(6): 998-1009.

So, what does this mean for developing habits that generate SA? It’s hard to say. Many of the behaviors studied are relatively simple and not performed in stressful situations like resuscitation. Furthermore, we are generally interested in measuring by event as opposed to by day due to tremendous variability in daily occurrences. However, two patterns emerge from what data does exists. First, most of the gains toward generating habit automaticity come in earlier repetitions. Second, the behavior must be repeated.

4. Evaluate the routine and, if it isn’t working, change it!

One of the major downfalls of just about any habit is dissatisfaction. People either never establish the habit or the get frustrated when an automatic habit isn’t working. As the SA routine is established it is important to try to obtain qualitative and quantitative data that demonstrate benefit.¹⁷ It it’s not having the intended effect, that’s fine. Use the data you’ve collected in conjunction with opinions and suggestion from other team members to adjust the routine as needed. The routine you develop can be changed as you see fit, albeit major changes will one again require many repetitions to become automatic.

5. Always remember why you’re trying to develop the routine

When trying to fundamentally alter a pattern of behavior, time and time again it’s evident that intrinsic motivation is seen as a key to success.^18,19 Extrinsic motivation is only marginally helpful and it’s effects don’t last. Likewise, just doing it because it’s “a new thing we have to do” doesn’t work very well either. The key is to remember that the SA habit is being adapted to make you and your team better providers. It’s designed so that you can have insight into what’s going on in a very dynamic environment. Its purpose is to draw attention to important things so that issues can be observed and problems can be avoided before they become catastrophic. Its purpose is to enhance performance and safety in resuscitation. Kindling this internal desire can go a long way to developing and maintaining strong SA routines.

The Importance of SA Behavior as Habit

So, why is it worthwhile to go through all the time and trouble of making active SA scanning a habitual behavior? After all, if we simply tell people these things or in some way contort important elements of SA into a checklist won’t that be adequate? Perhaps. However, in conditions where SA is most important it is unlikely that the conscious cognitive faculties of one’s frontal and prefrontal cortex will be functioning well enough to simply remember to pay attention to a list of things.

In stressful situations, especially in ones with overwhelming sensory inputs, the capability of the working memory is substantially compromised. Activation of the hypothalamic-pituitary-adrenal axis and increased sympathetic tone result in the release of hormones and other neurochemical mediators, such a cortisol, that change the way we process information and make important decisions.^20,21,22,23 Important structures in the brain like the amygdala modulate the activity and communication between the anterior cingulate cortex, prefrontal cortex, and various sensory corticies, which effect how we recall and incorporate information “we know” into choices at a given point in time.^24,25 Generally speaking, the net effect of these neurochemical processes is to decrease explicit memory processing (facts and information we consciously try to recall) and increase implicit memory processing (unconscious memories which usually have a distinct emotional referent). I would submit that we can all recall a point in time during training when we were asked a question by a superior and “drew a blank” or during a stressful resuscitation when we forgot a seemly elementary piece of information.

As it turns out, when we are stressed we tend to default to habituated behaviors. Goal-directed, conscious processes are impaired and we fall back on what we know, what we’ve been taught to do, and what we’ve already practiced.^26,27,28 In the context of addiction behavior, this fundamental process is thought to be the reason why stressful situations tend to trigger relapses in individuals that have previously abused alcohol and other drugs.²⁹  Thus, by making active SA behaviors a habit, there may be an increased likelihood that one will be able to maintain SA in chaotic and stressful circumstances. As the old adage in the military special operations community goes: “You don’t rise the occasion…you fall to the level of your training.”

Limitations

There are some important limitations to this suggestion that should be mentioned. First and foremost, there has not been an investigation of developing these active scanning habits. Therefore, it cannot be stated that such a concept has demonstrated clinical outcome benefit. That said, seeing as how there are validated tools developed to measure SA, perhaps this is a viable area of investigation in the near future.

Not all habits are helpful or beneficial. It is well known that “bad habits” can be counterproductive, dangerous, and difficult to eliminate. Therefore, it is of paramount importance that significant effort is spent to ensure that the system of active scanning is carefully developed. The goal is to imprint and effective habit. While it is generally stated that “bad habits are difficult to break”, such habits may be less difficult to alter or change.^4,19 As mentioned above, if the scanning system doesn’t seem to be generating the desired effect, go ahead and change it. If you maintain the same cue or trigger, it is often possible to alter the habit (i.e. the active SA behavior). It simply takes more repetition to ingrain the new habit.

Key Points

• SA is the group of cognitive skills involved in perception, comprehension, and anticipation of future events from information available in the surrounding environment
• It can be divided into two major subcategories: local and global SA
• SA is critical in high-risk situations, including medical resuscitation, and failure to maintain it has been associated with increased error
• A number of validated tools have been developed in medicine and other professions to measure SA
• As a cognitive skill, SA can be taught and developed
• SA should be developed as an active process and that active process should be converted into a habitual behavior
• The reason for developing SA as a habit is that in stressful situations, when cognitive load is high, we naturally fall back on habits that we’ve learned

More on Situation Awareness in Resuscitation

Stay tuned, in Part 3 I'll discuss a handful of additional topics and highlight additional examples of how some great resuscitationists in the FOAM world have addressed this topic.

References

1. Brewster BC, Brons RK. Task Force on Rescue—Rescue Techniques. In: Bierens JJLM, ed. Handbook on Drowning. Berlin: Springer; 2006:193-308.
2. Combat Aircraft Fundamentals. US Air Force Tactics Techniques and Procedures. 3-3 Guardian Angel. 19 October 2009.
3. Washington State Department of Transportation. Scanning Techniques and Sighting Characteristics. In: Aviation Emergency Services Aircrew Training Reference Text. March 2008 Version. Accessed October 22, 2016. Available at [http://www.wsdot.wa.gov/NR/rdonlyres/50010C1C-D7B8-4684-B556-62DC4CF51AA2/0/WSDOTAircrew..]
4. Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business. Random House Publishing Group; 2012.
5. Graybiel AM. Building action repertoires: memory and learning functions of the basal ganglia. Curr Opin Neurobiol. 1995;5(6):733-741.
6. Graybiel AM, Aosaki T, Flaherty AW, Kimura M. The basal ganglia and adaptive motor control. Science. 1994;265(5180):1826-1831.
7. Graybiel AM. Habits, rituals, and the evaluative brain. Annu Rev Neurosci. 2008; 31: 359-387.
8. Lally P, Wardle J, Gardner B. Experiences of habit formation: A qualitative study. Psychology, Health & Medicine. 2011;16(4):484-489.
9. Graybiel AM. The basal ganglia and chunking of action repertoires. Neurobiol Learn Mem. 1998;70(1-2):119-136.
10. O’Neill J, Conzemius A. The power of smart goals. Using goals to improve student learning. Bloomington, IN: Solution Tree; 2006.
11. Oettingen G. Future thought and behavior change. European Review of Social Psychology. 2012; 23(1): 1-63.
12. Chapman J, Armitage CJ, Norman P. Comparing implementation intention interventions in relation to young adults’ intake of fruit and vegetables. Psychology & Health. 2009; 24(3): 317-332.
13. Gollwitzer PM, Wieber F, Myers AL, McCrea SM. How to maximize implementation intention effects. In: Agnew CR, Carlston DE, Graziano G, Kelly JR, eds. Then a Miracle Occurs: Focusing on Behavior in Social Psychological Theory and Research. New York, NY: Oxford University Press; 2010: 137-61.
14. Gollwitzer PM, Sheeran P. Implementation Intentions and Goal Achievement: A Meta?analysis of Effects and Processes. Advances in Experimental Social Psychology. 2006; 38: 69-119.
15. Maltz M. Psycho-Cybernetics, A New Technology for Using Your Subconscious Power. New York, NY; Pocket Books: 1960.
16. Lally P, van Jaarsveld CHM, Potts HWW, Wardle J. How Are Habits Formed: Modeling Habit Formation in the Real World. Euro J Soc Psych. 2010; 40(6): 998-1009.
17. Burke LE, Swigart V, Turk MW, Derro N, Ewing LJ. Experiences of Self-Monitoring: Successes and Struggles during Treatment for Weight Loss. Qual Health Res. 2009;19(6):815-828.
18. Dean J. Making Habits, Breaking Habits. Boston, MA; Da Capo Press: 2013.
19. Deci EL, Ryan RM. Intrinsic Motivation and Self-determination in Human Behavior. New York, NY; Springer: 1985.
20. Gonzales L. Deep Survival: Who Lives, Who Dies, and Why. W. W. Norton & Company; 2004.
21. Wolf OT, Kuhlmann S, Buss C, Hellhammer DH, Kirschbaum C. Cortisol and Memory Retrieval in Humans: Influence of Emotional Valence. Annals of the New York Academy of Sciences. 2004;1032(1):195-197.
22. Ledoux J. The Emotional Brain: The Mysterious Underpinnings of Emotional Life. Simon and Schuster; 1998.
23. LeDoux J. Synaptic Self: How Our Brains Become Who We Are. Penguin; 2003.
24. Gray TS. Amygdaloid CRF Pathways: Role in Autonomic, Neuroendocrine, and Behavioral Responses to Stress. Annals of the New York Academy of Sciences. 1993;697(1):53-60.
25. Kim JJ, Lee HJ, Han J-S, Packard MG. Amygdala Is Critical for Stress-Induced Modulation of Hippocampal Long-Term Potentiation and Learning. J Neurosci. 2001;21(14):5222-5228.
26. Schwabe L, Wolf OT. Stress Prompts Habit Behavior in Humans. J Neurosci. 2009;29(22):7191-7198.
27. Smith DA, Bolam PJ. The neural network of the basal ganglia as revealed by the study of synaptic connections of identified neurones. Trends in Neurosciences. 1990;13(7):259-265.
28. Schwabe L, Oitzl MS, Philippsen C, et al. Stress modulates the use of spatial versus stimulus-response learning strategies in humans. Learn Mem. 2007;14(1-2):109-116.
29. Sinha R. The role of stress in addiction relapse. Curr Psychiatry Rep. 2007;9(5):388-395.

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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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