As we all are aware, veterinary emergency and critical care medicine and surgery requires a high level of information recall, physical examination skills and technical, clinical abilities. However, to survive in such a high pace, high risk environment also requires proficiency in a range of non-technical areas such as communication, stress management, cognitive reflection, and self-care.

In many high stress performance-based activities, successful proponents devote a significant amount of their preparation to the acquisition of psychological skills to manage attention and arousal. Under-arousal is associated with a lack of performance effort, whereas hyperarousal can produce chaotic inattention at the expense of execution. The effects of stress upon performance and the key importance of matching arousal state to the task at hand is based on an individual’s appraisal of the planned work versus the available resources, the complexity of the task and the relationship between the stressor and the activity, as well as prior experience and coping strategies (both innate and acquired).

Once task demands outstrip perceived resource availability, a threat or stress response—with physiologic sympathetic system consequences—ensues. This increased sympathetic tone, designed through evolution to ensure the individual’s survival, unfortunately has adverse effects on the performance of complex tasks:

As well as these more externally apparent effects, the ‘perceived threat’ response also has impacts upon attention, working memory, decision making ability, and team-related behaviour.

Unfortunately, in a clinical environment, these stress threats can have multiple impacts upon each individual as well as on the interaction between team members.

A number of different psychological techniques can be employed to help teach the body to cope with the transient effects of stress and better manage the situation. It is currently unclear, but appears likely that repetitive training in these techniques, as well as their application in stressful contexts may have a beneficial effect in reducing the degree and impact of chronic stress upon individual mental and physical health. One key factor that appears highly relevant for busy veterinary practitioners (who may not have much time to practice these sorts of things in isolation) is that these ‘stress-ameliorating techniques’ do not appear to be context-specific; i.e., performing these techniques is as protective in a busy work environment as it is when asking the bank manager for an extension to the overdraft or when you enter the exam hall, and (like most training exercises), repetition has cumulative beneficial effects.

Training Techniques

This lecture will present two different processes for helping deal with complex environments: the first focused on the individual, with the second centered around improving team performance via controlled leadership. Delegates will notice similarities between both techniques and a variety of calming/focusing systems employed in meditation, martial arts training, and other fields.

‘BTSF - Beat The Stress, Fool’ as proposed initially by Mike Lauria, a USA emergency physician who was previously trained as a military pararescue technician (like a helicopter paramedic but whilst being shot at—probably a fairly stressful environment in most people’s opinion!):

• B - Breathing: square breathing - deep, controlled - 4 seconds in, 4 seconds hold, 4 seconds out, 4 seconds hold. Reduces heart rate and blood pressure.
• T - Talk: self-talk - can either be self-confidence driving (“you can do this,” “you’ve done this before”) - affirmation statements - or can be verbal descriptors of the task to be performed - rehearsal statements. These also serve as a useful anchor point in reminding other team members of what is about to happen.
• S - See: visualize the task to be performed. Mental model creation (Physical Environment Task Timing Learning Emotion Perspective) is a vital step in technical skill acquisition; it needs to be based on having witnessed or performed the task previously, together with iterative guidance from a skilled practitioner for best results (deliberate practice). Incidentally, repeated visualization of accurate mental models appears to be just as good in maintaining skills as performing the live task.
• F - Focus: use of cue words - either to assist with T & S in cognitive reframing (“now placing the wire”) or to help trigger previously learned physiologic aids (“calmly”). The second approach, calm doon (“calm down” in Glasgow dialect!), devised by Dr. Stephen Hearns, an emergency medicine consultant and lead of the Scottish helicopter medical retrieval service, utilizes some of the same self-calming processes, but recognizes that clinical emergencies are dealt with by teams:
• C - Controlled breathing. Slow breathing rate to 8 breaths per minute, 8 seconds per breath.
• A - Articulate. Pause for a rally point when tempo allows. Share your observations and how you are feeling. Seek advice and opinions from the team.
• L - List and prioritize. Agree a list of required actions and which ones are most urgent.
• M - Mental model. During the rally point aim to achieve a shared and accurate mental model throughout the full team. Problems, resources available, objectives, actions. Leaders should avoid stating their model first - let others speak then summarize.
• D - Delegate. Delegate tasks and decisions safely. Delegate to those known to have the required competencies. Distribute tasks evenly throughout the team.
• O - Outside. Remove yourself from the auditory and visual stimuli of the situation for a short period to cognitively reframe. Think about or do something simple and familiar.
• O - Outsource. Make use of cognitive guidelines. Phone a trusted colleague who can help with decision making.
• N - Nutrition and hydration. For prolonged high-pressure situations ensure you eat and maintain hydration.

More advanced practice techniques can also be employed, such as stress inoculation training, as well as overtraining in ‘dry lab’ drills in CPR, Seldinger technique, difficult airways, laparoscopy, etc., although it should be remembered that routine ‘recipe-based’ overtraining can result in rigid mental scripts and non-adaptive behaviours (i.e., the inability to troubleshoot).

Stress inoculation training and dry lab drills can also be useful in team training—for familiarity with a challenging environment, experience with techniques and, therefore, acquisition of shared mental models, as well as refinement of communication skills and the mutual recognition of the importance of a well-balanced team structure. The same comments regarding the importance of varying team composition (creating ‘flash teams’) and the familiarity of the training scenario apply to team training sessions just as much as to the individual skills training described above.

Unfortunately, traditionally, it has always been assumed that for highly skilled and motivated individuals (such as doctors, vets, and nurses) effective team behaviours develop naturally and organically by way of a semi-random process of trial, error, and repetition. This is in complete contradiction to other high-stakes performance professions, where team training is recognized as vital in organizational culture. In team training scenarios a number of other factors have been shown to be useful in generating effective team building and shared mental models:

• Maintain a common language.
• Set common expectations - pre-briefing.
• Modify team structure to meet dynamic patient needs.
• Adaptive coordination.
• Thorough and flat-hierarchy debriefings.

In addition, the creation of a logistically ‘clean,’ planned, consistent clinical environment cannot be over-emphasized, with this equally being altered and adapted as experience determines. Three key times are vital for this to be effective—well before, immediately before, and in real time (during).

As evidenced by other high-performance teams from other settings—emergency services, the military, elite sport—familiarity with and application of the techniques described in this lecture will over time prove beneficial to the individual, to their colleagues, and, perhaps most importantly, to their patients.

References

References are available upon request.