03: simulation, visualization, and pressure with
Andrea Austin, MD
This episode is a conversation with Lieutenant Commander Andrea Austin, MD, from the Naval Trauma Training Center at USC + LA County about the importance of simulation, visualization, and pressure as a creative force.
Many non-crucial details of emergency medical cases, like when a case happened or the age or gender of the patient, have been changed randomly to preserve patient confidentiality. As always with the Emergency Mind Podcast, the goal is not to provide medical advice or commentary on medical care, but to explore best practices and ways that we can all improve how we think during an emergency and apply knowledge under pressure. Additionally, the views expressed on the podcast are personal views and do not represent the views of the employers or organizations at which we work.
05:33— Hypoglycemia (critically low blood glucose (sugar)) can manifest in a number of ways, ranging from mild confusion and lethargy to coma and even death. It can also mimic an acute stroke with global or focal neurological deficits. Its presentation is extremely varied and must always be kept in mind While hypoglycemia is a serious problem for people of all ages, it can be especially critical for young babies who lack many of the metabolic resources of older humans and therefore can rapidly decompensate. This can result in (among other things) the episodes of not breathing (apnea) that Dr. Austin describes subsequently. Hypoglycemia is easy to miss since it can present in a wide variety of ways and is not always obvious on the initial approach to a patient. Given these features (critical situation, challenging to see on initial approach, must not be missed diagnosis) it is particularly amenable to a systems-based approach that dictates all ill appearing children should have a sugar checked to try to prevent missed cases.
06:43—An “IO” or intraosseous line is a form of access designed to get medications and/or fluids into a patient during an emergency. Unlike an “IV” or intravenous line which is placed into a vein, the IO is drilled directly into a patient’s bone. An example of an IO delivery system can be found here. Descriptions of where IO’s can be placed, including the proximal tibia and distal femur described by Dr. Austin can be found here. A great video involving both a discussion of IOs and the actual placement of an IO into a patient (if you’re not medical / trauma, consider whether or not you want to watch this) can be found here.
10:30— Recognize that even if you are not the best in the universe at a skill, you are the single best chance at getting through this situation. This is an important part of the Emergency Mind skill of accepting the reality of the situation – we don’t have to like the chances that we have, but we do have to recognize that it’s up to us, that we are the best right here right now.
12:44—A good reminder for when it feels like we’re the only ones struggling with something: all of us have facets we are working on improving, even super-accomplished emergency docs like Dr. Austin.
13:00—So many good things to unpack here. Understanding the differences between what we can and cannot control is one of the key pillars of the Emergency Mind. We cannot control everything, but we can control ourselves and our internal environment. There’s a ton to dig into about it: consider starting with Meditations by Marcus Aurelius, the Stoic Philosopher and Roman Emperor. I misquote him at around 15:32, the actual quote is “You have power over your mind, not outside events. Realize this and you will find strength.” Really can’t say enough about how important that is for thinking during emergencies. We must let go of what we cannot control and focus where we have the ability to act. I’d also recommend Seneca’s Letters from a Stoic which is the book that was sitting on the table next to us during this interview.
17:30— There’s a lot to learn about applying knowledge under pressure from the world of poker, and professional poker player Annie Duke wrote an absolutely incredible book called Thinking in Bets. This book fundamentally changed the way I process and learn from individual patient cases, both in terms of my ability to improve my medical skill and my ability to decouple my sense of self from the outcome of any one case. The matrix she describes of win/loss vs success/failure is a common feature of post case analysis, both when I’m teaching residents and when I’m practicing solo.
20:30—The Sim Man is a type of high-fidelity emergency simulation mannequin that is just really excellent for providing teams with the ability to simulate emergency and non-emergency medical situations. More information can be found here.
20:49—“Your patients don’t care that it’s rare. They came to you expecting the best.” This is really well said- for a patient or their family, it doesn’t matter if an event happens every day or once during a career. In situations like the emergency department, where as Dr. Austin goes on to explain, you have to be ready to successfully perform a rare event every single day, how do you keep your skills sharp and your teams trained and ready? I agree with Dr. Austin that simulation and visualization are key. Surgeon and writer Atul Gawande also dives deeply into several of these ideas in his excellent books The Checklist Manifesto and Complications.
21:00—Pediatric jet ventilation is a technique for delivering oxygen to an unstable child during an emergency by placing a needle through the child’s neck into their airway. It is an excellent example of a rare event that nevertheless emergency doctors must always be ready and able to perform. Details are here.
21:55—The folks I was lucky enough to get to work with during my residency training are the simulation experts at the BWH STRATUS Center for Medical Simulation. They are wizards at high and low fidelity simulation and at throwing curveballs.
26:05—Muhammed Ali said, “The fight is won or lost far away from witnesses - behind the lines, in the gym, and out there on the road, long before I dance under those lights.” The way we train is inexorably linked to the way we actually perform under pressure, for better or for worse. Some of the folks who trained me reflect on this brilliantly during a discussion of their actions after the Boston Marathon bombing in 2013. Their article in the New England Journal of Medicine can be found here.
27:10—A subarachnoid hemorrhage is a subtype of acute bleeding into the brain. An “MI” or myocardial infarction is another way to say “heart attack.” Both of these events can happen suddenly and without warning and have been known to cause people to crash their cars. In this circumstance the patients might arrive as a “trauma” case, and the underlying medical cause of the accident (bleeding or heart attack) might not be immediately obvious.
27:34—We spend a good deal of the next part of the podcast discussing heuristics, which are mental shortcuts designed to be employed when a complete solution to a problem is impossible or simply too hard given time and resource constraints. There is an enormous amount to dig into about heuristic thinking in medicine, and it’s beyond the scope of the show notes here to cover. The basic idea though is that during an emergency situation, where information and resources are both at premiums, heuristics are the decision rules we use to simplify and focus our thought processes and (hopefully) arrive at a good decision quickly. As with all approximations however, they never fully represent reality and they are only as good as (1) the information you put into them and (2) your choice of heuristic, among other things. If you’re interested in learning more I’d consider starting with the excellent book by Daniel Kahneman, Thinking, Fast and Slow.
27:45— Apologies for the total hyperbole on my part. I can’t actually claim this has “always” been a rule of sim. I do think that you get out of it what you put into it is a good rule in general though.
28:06—Peak: Secrets from the New Science of Expertise is an excellent book by Anders Ericsson and Robert Pool about training and developing expertise. It is really, really good, and changed a lot of my thoughts about how I personally train, both in emergency medicine and in jiu jitsu. I first heard about it as an excellent episode of the EMCrit podcast, which can be found here.
33:38—Between this and the quote at the end, The Warrior Mindset is definitely high on my list of what to read next.
38:10—The discussion we’re having here about recognizing when we are forced to act vs being under pressure but not forced to act in this second is something I personally find very interesting and work on a lot. There’s a balance in there – something Jocko Willink (former Navy Seal and leadership expert with an amazing podcast) might highlight a dichotomy in leadership and action—how do I find the right line with being aggressive and proactive during a case while also slowing down and bringing more flexible and nuanced thought processes to bear. I’m a work in progress on this one for sure.
39:49—There’s a lot of interesting work out there about the benefits of “tactical breathing” or “box breathing,” along with its variations. (Here, for example, or here.)The basic idea is to visualize a square, where each side of the square is one part of the breath and the length of each side corresponds to the amount of time that part of the breath takes. In a square breath, you breathe in for a count of four, hold the breath in for a count of four, breathe out for a count of four, and hold the breath out for a count of four. As Dr. Austin describes, different people might alter the technique slightly and find better results with variations of the box breath.
44:19—I think this is really big. You have to know your stuff, you have to be good at the knowledge part of medicine (as Dr. Austin says later, you have to be good in your lane) but what we spend our time thinking about is how to slow down and bring calm to the chaos. There’s a great interview of expert drummer Dave Elitch by author/podcaster Tim Ferris (here) that talks a lot about Elitch’s mantra when training of “Slow down. Do it again.” The more I train and practice, the more important I think this idea is. As I say in the podcast, slow down and make sure the knowledge gets to where it needs to go.
45:26—“The quietest teams tend to be the best teams.” Very deep idea here and something we’re for sure going to come back to in future episodes. Immediately makes me think about the Sterile Cockpit Rule, which dictates complete silence in the cockpit of an airplane during the crucial phase of takeoff and landing apart from communication needed to fly the plane
48:09—A couple of terms might need defining here. GSW: Gun shot wound. Tension physiology refers to a pneumothorax (air leak from the lung into the chest cavity) caused by an injury which creates a one-way valve allowing the air to leak into the chest but not leave. As the pressure builds up in the chest it becomes harder and harder for the heart to beat and can eventually stop the heart if untreated. This is called a tension pneumothorax. Treatment is accomplished by decompressing the chest via a large gauge needle or chest tube placement. There’s a great video explaining it here from the folks at PrepMedic (no affiliation).
48:44—Explicitly stating the most important goal—we have to get the patient to the OR in 5 minutes—is a great way to make sure the entire team shares your mental model of what the goal is in a particular situation.
50:28—“Competency is the bedrock…everyone on the team has to be competent in their lane.” Build competency in your skills, then add pressure and train and train with more complicated tasks and scenarios. This one minute is probably the most rich lesson on the backbone of creating a simulation process I’ve heard.
55:55—This is really good advice – make a list of the situations that bother you, that you’re worried about, then make a direct plan to train and over-train those exact situations. Dr. Austin’s commentary on how to really use visualization, on a really deep level, is crucial in developing these training plans which echo in many ways the ideas expressed in Peak: Secrets from the New Science of Expertise by Anders Ericsson and Robert Pool.
1:00:00—Once again, The Warrior Mindset is definitely high on my list of what to read next.