Despite resuscitation teams operating in extremely high stress environments and such stress being known to substantially impair optimal performance, historically very little attention has been paid to preparing these teams to mentally function at their best. Recently strategies taken from other high stress environments such as armed “special forces” teams and high performance athletes have been applied to critical care with some impressive demonstrated and potential benefits.
Several excellent critical care podcasts (links provided below at the end) by Jason Brooks, Chris Hicks, Mike Mallin & Scott Weingart provide an excellent insight into how we can specifically train our minds for the rigours of the resuscitation room, using psychological techniques from “stress inoculation training” or “stress exposure training”. Note, while this post focuses on the resus room, these techniques could be applied to other stressful situations at work or in your personal life.
I’ve summarised my interpretation of these strategies below, included some key quotes and paraphrasing from the speakers and ordered these tools in terms of when they can be applied temporally in relation to the stressful moment.
Before the moment
This involves performing a mental visualisation of the anticipated resuscitation before it occurs. This typically would be performed well in advance in dedicated time in a scripted way within teams, however a brief version could be applied in the minutes prior to the arrival of an actual critically unwell patient. Essentially this is a form of simulation as the mind is a tremendous simulator. The key is to make the visualisation vivid and to visualise optimal performance and success in challenging scenarios. Interestingly teams that Hicks studied who sat in a room and merely spent time visualising anticipated resuscitation scenarios performed better in simulation testing than teams who spent that same time doing active training in formal resuscitation strategies and protocols.
While real simulation training is an ideal way to inoculate ourselves from stress by practicing the performance of required tasks under simulated stressful conditions, mental visualisation is an easy adjunct that can be performed all by yourself.
“What we think dictates what we feel which becomes our experience” … so “guiding our thoughts becomes essential” says Brooks.
Use 5 minutes at the start of the day to program our subconscious mind with positive thoughts about how we want to perform in the resuscitation. For example, program these thoughts: “When I enter the resus room, I will be focussed, I will think clearly, I will retain situational awareness …”
Envision a scenario that causes a hightened emotional reaction such as a resus – allow yourself to trigger those emotions and view the scenario from a detached 3rd person perspective. Then rewind the scene and visualise the same scenario but this time seeing and feeling solutions and optimal response patterns.
In the moment
“Reframe the impossible as the achievable” describes Brooks.
Cognitive Reframing, is about taking a large and complex task and breaking it into smaller goals so that the “impossible” becomes cognitively reframed as “achievable”. It is borrowed from performance athletes who rather than focus on the insurmountable task of winning a season/championship, cognitively reframe to focus one “one game at a time” and then even further on smaller achievable targets during “the next quarter” or even just “the next play”.
Similarly a complex and long resuscitation can be reframed for participants by making short term achievable goals either for the whole team or in small team sub-sets eg “for the next 5 minutes the airway team’s task is to secure the airway”.
Tactical breathing and Verbal Centering
Tactical breathing is essentially just yoga/meditative breathing rebranded with a stylish “armed forces” nomenclature.
Simply, take a slow deep inspiration over 3 seconds – hold – then expire over 3 seconds and the hold again between breaths. Can do this once or repeat a couple times.
This very quick strategy rapidly reduces stress levels and helps focus the mind.
Additionally, you can combine tactical breathing with a Verbal Centering technique where on the exhalation phase you use “positive self talk” to mentally focus and prepare for the stressful scenario – to “get in the zone”. These statements also help cognitively reframe the mind to believe that you have the resources for the task at hand. Phrases such as “I got this”, “Ready”, “Showtime” and “Focussed” when used repeatedly in same stressful scenarios can quickly bring the mind back into the “zone” where it needs to be for maximal performance.
Mindfulness & Acceptance
This involves using mindfulness to identify negative thoughts and emotions as they appear, view them from a detached 3rd person perspective and acknowledge them as being a non-functional response to the moment but not the moment itself and then set them aside. This helps prevents theses thoughts from spiralling into a range of emotional responses that would interfere with your mental function.
Brooks gives the example of a doctor who when he feels himself getting frustrated, he projects that thought of “frustration” onto an imaginary screen in front of him, stares at it, acknowledges it, then takes a deep breath, puts it to the side and steps back into the moment with total presence of mind.
After the moment
“With reflection, we break it down … draw out the nuggets … learn how to get better … apply that and move forward”
In addition to the standard “medical debrief”, after the resus reflect on the thoughts, emotions and actions that occurred to learn from the good and the bad. Better still, after reflecting, use the techniques discussed above to positively alter our thoughts and emotional reactions and visualise optimal performance.
All the time
In addition to these specific resuscitation targeted strategies of stress inoculation training, regular mental exercise to improve concentration, focus and well being is also advocated by Weingart using meditation. He advocates 10 minutes a day though multiple short 1-2 minutes bursts of meditation slipped into pockets of available time can be a useful and more achievable strategy for the beginner.
For a more in depth understanding of these strategies I highly recommend listening to these podcasts.
Additionally, for a more thorough understanding of the field of stress inoculation training and its application in critical care including, in addition to mental preparation, the physical skills training involved, check out this emcrit post