07: Algorithms and Jazz in the ER with Dana Sajed, MD 

In this episode, we dig into algorithmic and improvisational thinking in music and in the ER with the emergency doctor, ultrasound expert, and deeply cool human Dana Sajed, MD. 

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.

05:50— We cover a lot of ground regarding training strategies with Dr. Austin in Episode 03, but what I refer to here—being good in our own lane—is at about 50:30.

06:50—Dr. Sajed is not alone in these feelings. Many of us can feel underprepared in various areas—either technical like iv placement or mindset like stress management—as we begin residency. A 2019 study in the Western Journal of Emergency Medicine (here) of interns starting their emergency medicine training highlighted some of these gaps in training and concluded that targeted interventions were needed to improve well-being during residency and potentially avoid later burnout.


08:15— As we have talked about in other episodes, the fundamental first approach to any emergency follows the ABC—Airway, Breathing, Circulation—algorithm. The purpose of this framework is to ensure that the most important and potentially life-threatening things are taken care of first, so, for example, you don’t fix a small cut on someone’s hand before you address the hemorrhaging gunshot wound to their chest.


09:00—“Improvisation comes after you’ve learned that initial algorithmic approach.” This idea is true in anything that I have ever studied, from martial arts to foreign languages to medicine, and it is something that Dr. Sajed and I spend a lot of time digging into in this episode. We don’t talk much about ultrasound (Dr. Sajed’s expertise) during this podcast, but the idea of learning algorithms to support your initial approach, mastering your skills, then moving on to improvisation is exactly how Dr. Sajed (and a lot of other wonderful folks) taught me how to perform emergency ultrasound. If you’re interested in more about emergency ultrasound, I would recommend this book by Drs. Vicki Noble and Brett Nelson, both of whom I’ve been lucky enough to work with.


13:00—Here are Dr. Sajed’s recommendations for books to read at the beginning of thinking about thinking under pressure. Heat: An Amateur's Adventures as Kitchen Slave, Line Cook, Pasta-Maker, and Apprentice to a Dante-Quoting Butcher in Tuscany, by Bill Buford, and Kitchen Confidential: Adventures in the Culinary Underbelly by Anthony Bourdain.


19:00—Recently I’ve been really enjoying a podcast called The Knowledge Project, from Shane Parrish and the folks at Farnam Street. One of the many reasons I enjoy it is Shane’s love of digging into mental models and exploring the algorithms that his various guests use to excel in a variety of aspects in their lives. If you’re interested in exploring different types of algorithmic thinking, I highly recommend it. I particularly like this episode with Daniel Kahneman, this episode with Scott Page, and this one with Jim Dethmer.


21:00—Looking back, we actually talk about throwing algorithms under pressure in basically every episode, since I think it is a crucial part of applying knowledge under pressure. The book Peak: Secrets from the New Science of Expertise, by Anders Ericsson and Robert Pool, that I mention is also something we bring up a lot. :) Dr. Sajed talks a lot about this at the end, around 46:00

23:35—Premeditatio Malorum is the Stoic philosophy concept of visualizing bad outcomes and learning from them. Author and Stoic Ryan Holiday has a great blog post where he digs into the details it here. There’s also a good article from author James Clear about it here. In the ER, we deploy this idea regularly as we think through what the next steps might be in any situation – Dr. Sajed talks through a good example of this regarding airway management at around 27:30.


26:50—An amazing video of Miles Davis can be found here

30:50—Mastering our instrument is a practice that never stops. No matter where we are on the curve of learning, we are always still learning and always still practicing with our minds and our instruments. Fundamentally I think the love of practice, the love of getting better and tuning ourselves is one of the greatest joys. Two quotes come to mind about this: First, from the Stoic philosopher Seneca, who wrote: “ Second, from the Karate master Gichin Funakoshi, who wrote that “Karate is like boiling water: without heat, it returns to its tepid state.” We must continue to practice our own instrument to keep living.


32:40— I would highly recommend the book Thinking in Bets, by poker expert Annie Duke, which is an analysis of how we succeed and fail at thinking about risk and about outcomes during extreme uncertainty. This book changed the way I process and learn from individual patient cases and it is often a topic of discussion with fellow doctors. She also wrote a great article which summarizes some of the concepts here.


34:30—I love the idea of what Dr. Sajed does here – to proactively run his mind back over every single case he sees and try to learn from and improve himself with each case. I’ve long done a similar thing for the most complicated cases, post-processing them over and over—usually during the course of a run—and work through how different options might have played out and what I can do better next time. There’s no right or wrong way to do these post-process visualizations. Dr. Sajed describes his personal method at around 39:00.


41:45—Feedback and mentorship matters in emergency medicine as in everything. Actively seeking out ways to improve and get better is a key skill, and one I keep working on in my own practice. The more open we are to new ideas and feedback, the better we are at applying our knowledge under pressure. Implicit in this is the idea that we need to keep seeking discomfort and our edge as we keep mastering our instrument and learning how to improvise.


47:30—“Chaos is the standard of the universe…every time I walk into a shift, I expect that chaos.” I love this quote, and it reminds me of another quote by Seneca. “Between the earth and the stars, there is no easy path.” We should not expect things to be easy. We should expect chaos and plan accordingly. As Dr. Sajed says slightly later, “Embrace the chaos.”