11:Signal to Noise and Setting the Tone, Andrew Eyre, MD MS   

Setting the tone in a critical case, optimizing signal to noise ratio for learning, and the joys of simulation with Andrew Eyre, MD MS 

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.



01:11—Throughout this episode we frequently talk about Andrew’s work in medical simulation, much of which takes place at The Neil and Elise Wallace STRATUS Center for Medical Simulation at Brigham Health in Boston, MA. You can find the STRATUS center—which seriously is an amazing place—here, or here on Instagram.


Experience as a Paramedic and Driving on Icy Roads


03:00—In the US, “prehospital care” refers to any skilled medical care delivered before or during patient transport to an emergency facility. In this sense, it incorporates medical care provided by police and fire teams, as well by dedicated EMT and paramedic teams (depending on the location, these teams might be part of the police or fire teams or a separate team). For comparison, care provided by civilians on scene during an emergency is referred to as bystander care.


05:30— Debriefing after an event via a structured post hoc analysis can be a powerful tool for improving future team performance. This article from the Agency for Healthcare Research and Quality has a great breakdown of the how and why of performing a skilled debrief after an emergency.


08:00—The calmer we are in a crisis, the calmer everyone around us will be. The responsibility to and potential impact of staying calm under pressure is particularly high for leaders of teams facing stress, as this article in Fast Company highlights.


08:45—The image of a junior operator trying to rush around turns on an icy road and a more senior operator telling them to slow down and get there in one piece is so compelling. How often will slowing down and getting the turns correct actually get us there faster and better? More importantly- if you go so fast that you spin out on the ice and crash then you will never get the patient to the hospital and all the seconds you “saved” are irrelevant.


11:26—“Freaking out just never makes the situation better,” an important theme in The Emergency Mind echoed by multiple other podcast guests including Bret Whitman in Episode 10 and Prof. Gustavo in Episode 8, among others. An interesting parallel to this comes from the science fiction masterpiece Dune, by Frank Herbert, where several characters repeat the so-called “Litany against fear,” which states “Fear is the mind-killer. Fear is the little-death that brings total obliteration.”


15:30—Andrew’s technique of sharing his emotional model by expressly stating what he is feeling out loud to the room is a fascinating technique – similar in many ways to what Jodi Strock describes in Episode 9 about verbalizing what we’re feeling in difficult situations.  

Simulation and the Signal to Noise Ratio


16:50—The SimMan simulation model that Andrew describes is really excellent. This (somewhat dramatic) video shows an example of a team using the SimMan to practice team-based trauma care.  


18:20—“We let them fail, then we have them recover.” Training at the edge of our ability, where we are failing and then recovering, is crucial to continuing to get better. Dr. Dave Alred, in his book The Pressure Principle, describes this area where we train at and around the point of skill breakdown as “The Ugly Zone.” It’s important to call out that the idea is not training to the point of physical breakdown – if we go so hard that we hurt ourselves then we might have difficulty training again tomorrow (see above re: icy roads) – but instead that we train to the point of skill breakdown.

19:48—The thought that Andrew puts in here around tuning the signal to noise ratio (SNR) is deep and worthwhile. When you’re working through a training exercise, what is the best SNR to get the job done? The excellent folks at School of Grappling (for example here on Instagram) talk about this idea frequently when discussing how best to train in Jiu Jitsu – high SNR (drilling a particular move) might be useful for learning the mechanics of a move, while lower SNR (trying to apply the move in a free roll) might be more useful for learning how to spot the opportunity to apply the move.


21:45—Simulation as scaffolding: Andrew’s idea here that the idea of simulation is not to teach directly, but instead to provide moments that spark thought in learners and allow them to subsequently learn deeply on a subject.


Personal Practice and Team Leadership


25:50—Your job is not to know everything perfectly by yourself, but instead to get the knowledge of the entire room into the patient. I consistently think about this idea during complex cases – how do I facilitate the entire room working together?


28:15—Dr. Atul Gawande is an incredible writer and a profound thinker about how to build better systems of health, better doctors, and better people. I have read and deeply enjoyed his books Better, Complications, and The Checklist Manifesto.


29:00—I’m not 100% sure what Andrew is referring here to – most likely he means the book Blink by Malcom Gladwell.