Cognitive overload and prehospital emergencies
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Cognitive overload and prehospital emergencies
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Cognitive offloading for critical care retrieval by Stephen Hearns Everyone’s cognitive capacity is limited. It is easy to become overloaded and subsequently for our performance to be impacted. In medicine however, an overloaded cognitive capacity could be the difference between life and death. There is little room for healthcare professionals to be unfocused, yet retrieval medicine is comprised of unpredictability, critical time pressures and fast-paced emergency responses. Let’s face it, there’s never a time where we are more cognitively overloaded than at a multi-casualty incident. Cognitive overload in retrieval medicine results in an unsafe environment and compromised decision making. We need to rely on strategies and processes to reduce our cognitive burden. Eliminating the need to make decisions, allows for a better response to unpredictable scenarios. One strategy is to identify the predictable recurring components and plan for them. Practice implementing the plan, fine tuning the response and ensuring that the whole team is on the same page. It is critical that everyone is well versed and understands the processes and procedures. Furthermore, streamlining communication can have a significant impact on the outcome of high-pressured situations. It can also help us reduce stress and stay in control. Articulate and tell the team when you are overloaded. Encourage your colleagues to do the same when they are overloaded. Delegate and outsource decision making. Teamwork is critical and can make or break an outcome. Rely on writing lists and prioritising actions. It is an excellent way to seek clarity in high-pressured situations. Plan, practice and predict the predictable so that when the unpredictable happens, it has our full attention. Tune in to a DAS SMACC talk by Stephen Hearns on cognitive offloading for critical care retrieval. For more like this, head to our podcast page. #CodaPodcast
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Cognitive overload and prehospital emergencies
- @EMRSScotland @StephenHearns1
- Cognitiv e load Perfor mance
- Optimal perform ance Cognitiv e load Perfor mance
- Cognitiv e load Perfor mance Optimal perform ance Stress Reduced performance
- Cognitiv e load Perfor mance Optimal perform ance Stress Reduced performance Overloa d Safety compromis ed
- Cognitiv e load Perfor mance Optimal perform ance Stress Reduced performance Overloa d Safety compromis ed
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- Cognitive Cognitiv e load Perfor mance Optimal perform ance Stress Reduced performance Overloa d Safety compromis ed
- Cognitive Cognitiv e load Perfor mance Optimal perform ance Stress Reduced performance Overloa d Safety compromis ed
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- C ontrolled breathing A rticulate L ist & prioritise M ental model shared D elegate O utside O utsource
- Perfect Practice Predictable Plan @EMRSScotland @StephenHearns1
- @EMRSScotland @StephenHearns1
- “Everyone has a plan …’til I punch them in the face @EMRSScotland @StephenHearns1
- 47@EMRSScotland @StephenHearns1
Editor's Notes
- Cognitive Offloading For Critical Care Stephen Hearns
- This is the pre-hospital scene we all aspire to. Calm, controlled, safe, clinical care flowing
- The performance of this team is following the model described by Yerkes and Dodson in their stress-performance curve. As the cognitive demands upon us increase we become more stimulated, more engaged and our performance increases.
- Performance continues to increase until we reach a state of optimal performance. The sweet spot. We are in the zone. This is a pleasurable place to be. This is why we love our job as pre-hospital doctors, nurses and paramedics.
- There’s a problem though. Our cognitive capacity is limited. We can easily become cognitively overloaded, resulting in a reduction in performance.
- We can become so cognitively overloaded that we become unsafe.
- This prehospital team is cognitively overloaded. The scene is unsafe. Patient care is ineffective. Our amygdala senses danger. It passes a message to our pituitary which releases ACTH. This stimulates the release of adrenaline and cortisol. We develop tachycardia and tachypnoes. Our muscles tendse up.We start to perceive the situation negatively and pessimistically. Our bodies are getting ready to act aggressively or to run away. In a PHARM setting we lose control, we become quiet or we shout, things become unsafe for the patient and for the team.
- We have a word for this state of cognitive overload in Scotland.
- To provide the best care to our patients we need to try to keep our teams in the optimal performance sweet spot
- We need to put systems and behaviours in place to avoid them getting overloaded. Systems to keep us to the left of the curve.
- However with inefficient systems, even before our teams reach the patient the cognitive load on them is considerable.
- However with inefficient systems, even before our teams reach the patient the cognitive load on them is considerable.
- We all know that every retrieval is different. Every retrieval is unpredicatable
- So we can do a lot to optimise our performance in retrieval medicine by identifying those predictable components. We can carefully plan them, we can practice them and we can perfect them. If we perfect the predictable it allows the unpredictable to happen safely and efficiently.
- We need to drill our predictable set pieces.
- Emergency anaesthesia, blood transfusion, packaging. If we drill these enough we will develop system 1, automatic thinking.
- Our teams need to have guidelines, standard operating procedures. They need to be accessible to teams whenever they need them
- Guidelines need to be short, didactic and unambiguous.
- We need to supply our teams with easily accessible cognitive aides to reduce the cognitive burden on them during retrievals, especially for uncommon procedures and mission types.
- Our team supplies 30 different hospitals. All have different clinical capabilities and landing sites. Its impossible to retain the necessary volume of information. We provide the team with location guides as part of the EMRS iphone app.
- Aid memoirs for infrequently used pieces of equipment which aren’t intuitive.
- We’re never more cognitively overloaded as when we are responding to multiple casualty major incidents. Didactic action cards for individual team members are essential to allow optimal performance under pressure.
- You can’t have enough checklists to optimise performance. As well as pre-procedural checklists we should have lists for ensuring our readiness state at the start of shifts, care budles for sepsis, for neuroprotection and for leaving scene.
- For retrieval team leaders the most effective method of cognitively offloading is delegating decision making and practical procedures. We need to have confidence that those we are delegating are competent. Clearly defined written competencies are important. As is assessment of competence.
- Preparing equipment and troubleshooting problems adds to the cognitive load. Investing in optimal kit layout, prefilled syringes and back up devices saves time on scene and helps keep us on the left side of the curve
- Our teams need to have insight into the causes of of and behaviours associated with cognitive overload. The need to know how to communicate and to behave when performing under pressure.
- Felling unsafe or being affected by environmental conditions reduces our ability to perform. Training and equipping our services to control the environment improves safety and efficiency.
- We invest heavily in the best personal protective equipment for our team in Scotland.
- Individual team members can carry personal cognitive baggage during retrieval shifts. Pilots create a sterile cockpit, preventing unnecessary communication compromising performance. We should consider the concept of sterile shifts.
- Cognitive demands on operational teams can be reduced with effective central coordination and decision support systems
- We need to learn from other highly performing teams. The Sky cycling team embraces the concept of marginal gains. If we can improve performance by 1% in ten areas we can improve overall performance by 10%.
- Have systems to make event reporting easy and fast.
- Badge camera filming of retrievals allows us to objectively review communication and systems.
- All of these systems can move us to the left side if the curve to avoid poor performance due to cognitive overload. But what can we do if we do become overloaded?
- ASH Twitter Questions: Cognitive Offloading For Critical Care Stephen Hearns