05: Eliminating unnecessary opportunities for failure with

Amy Hildreth, md

This episode is a conversation with Lieutenant Amy Hildreth, MD, from the Naval Medical Center in San Diego, CA, about training for the unexpected and eliminating unnecessary opportunities for failure. 

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.

05:35— Amy brings up some really interesting questions here about what is innate in our response to an emergency, and what is learned / trained. I agree with her that most people generally want to help when someone is hurt, even if they might not totally know how to help. Calling 911 is always a great first step. There’s a lot in this episode about what anyone can do to help in a crisis, but training more is always a good idea. For ideas about how to train basic lifesaving techniques, check out the American Heart Association training here for medical emergencies, and the Stop the Bleed training here for traumatic emergencies.

08:30—I think it’s really important to hear this kind of story. Amy talks about how she shied away from blood and sickness, and never wanted to be a doctor but has since become an excellent clinician and leader. It’s a good reminder that no matter where we start, we can go on to develop the skills needed to act in an emergency. Applying knowledge under pressure is not for other people with other backgrounds, it is for us, whoever we are.


11:00— Andrea Austin (Episode 03) talks a lot about her experience in simulation and with what makes an efficient team – around 45:20 in that episode she hits on a similar idea to what Amy is describing here, stating that “The quietest teams tend to be the best teams.” That part of the episode is. Definitely worth a listen.

12:00—There’s a great video of the ABCDE algorithm here, and one of the initial approach to a trauma patient here.

12:50—We talk a lot about the idea of knowing how your resources and practice environment can affect your care in Episode 02 with Erik Anderson. See for example, around 06:00 where Erik talks about asking “what do we do in this situation in this hospital?”

13:15—“No one gets smarter in an emergency.” This is really true. The challenge then is to get smarter ahead of time and be able to deploy algorithms and other tools to supplement and support your thinking. Recently I’ve been listening a lot to The Knowledge Project, a podcast run by Shane Parrish and the folks at Farnam Street. They do an awesome job talking through different mental models and algorithms that we use to augment our thinking and support our decision making in different circumstances. Their blog is pretty awesome too.

14:50—Both models of thinking that Amy describes here – pathway / algorithmic thinking and free form thinking are deeply useful in the right circumstances. Especially in the first minute of a major case, we rely greatly on the ABCDE / trauma algorithms described above, then try to move smoothly into more flexible modes of thinking that allow for more complex decisions. Amy talks about this idea briefly at 16:15 too.


17:45—Go back to the beginning. Erik Anderson talks about this somewhat too in Episode 02 with his injunction to “go back to the bedside.” In both cases, Erik and Amy are describing returning to the beginning of the ABCDE algorithm when things start going poorly. The idea is that algorithmic thinking deployed in these moments of unexpected chaos will prevent errors and trump more free form thinking.

19:40—This is a great point – one of the best ways we can be ready to pvot and protect ourselves against locked-in thinking is to foster excellent communication with the team around us. Teamwork and team communication are indispensable in emergency medicine.

21:20—We originally recorded this episode in July, the month where the new residents step up into their next roles.

23:52—"Simulation: no one is going to die. Everyone is going to judge you. Love this idea. Training skills to be deployed under pressure requires training under pressure. Former Navy Seal and leadership expert Jocko Willink put it this way: “Don’t fight stress. Embrace it…Use it to make you think and learn and get better and smarter and more effective. Use the stress to make you a better you.”


26:30—For the Stoics, the idea was called Premeditatio Malorum, think ahead about all the bad things that could be happen and get ready for them. There’s a great piece about it here from the Daily Stoic. Amy also does a great job explaining how all of us can work on premeditation malorum both in and out of the emergency department. The key idea behind this is to use these visualization exercises not to overwhelm or be morbid, but to identify areas where you can start to upgrade your systems and level up your abilities. As Amy puts it, “what is the biggest emergency that you could handle?” think about that and get going.


29:50—Details about the stop the bleed course can be found here. A great video explaining how to put on a CAT (combat application tourniquet) is here from the awesome folks at North American Rescue.


33:55—Ok, Mr. Willis, you’ve been requested. If you’re reading this, I’d love to have you as a guest to talk about performance under the pressure of saving the world.