EM Mindset: Preparedness and the Mental Emergency Department

Author: Eric Shappell, MD (@ericshappell, EM Attending Physician / Medical Education Fellow, University of Chicago, Editor-in-Chief of EM Fundamentals) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

“How do you study?” and “What do you read?” are two of the most common questions I receive. For a while now my answer has started with “Read about something that makes you nervous.” I’d suggest the inquiring resident or medical student think of a patient presentation or chief complaint that makes their heart rate rise, then to go and devour everything about it they can find, the hope being that they come away confident and prepared for their next encounter with this problem. I still stand by this advice and give it out regularly; however, I’ve since expanded on this concept in hopes of encouraging more robust, goal-oriented understanding through case-based study and deliberate mental rehearsal.

The Mental Emergency Department

Rather than simply reading about a topic that makes them anxious, I now encourage my residents and students to imagine themselves in the emergency department while studying. In this “mental emergency department” I again challenge them to visualize the presentation of a patient with a nerve-racking complaint. This time, however, I recommend they walk through the encounter step-by-step in their mind, making decisions and visualizing actions in the order they would actually occur in their department. Any areas of uncertainty along the way should prompt reference to the clinical tools they have available on shift (e.g. pocket reference cards, Broselow tape, etc.) and, if the answer is still unavailable, reference back to the literature and/or consultation with experienced providers. Once the question is answered, they return to managing the case.

Goal-Oriented Clinical Questions

This case-based approach encourages learners to focus on initial preparedness and solidifying their knowledge around action items. For example, rather than reading through a textbook chapter looking for information on massive hemoptysis, in this model the learner focuses on chronologic, goal-oriented clinical questions: How can I optimize my team’s response when someone is rolled in on a stretcher coughing up blood everywhere? What needs to happen first? What equipment do I need? How should I position this patient? How will I know if I need to intubate? How can I temporize? Who can I call for help? While answers to questions such as those about positioning and equipment may be readily available in the literature, those about managing the team’s response and deciding when to pull the trigger on intubating are no less important, much more nuanced, and unlikely to be adequately answered in print. This exercise in stepwise visualization can help identify these occult dilemmas and allow the opportunity for mental rehearsal and/or discussion with others to formulate a mental model or “mind map” for addressing these issues when they happen in real life.

Rehearsal and Performance

The benefits of mental rehearsal are not limited to reinforcing the steps in a resuscitation or formulation of a mental model; rather, this exercise can also improve performance when confronted with a high-stress clinical scenario in real life. Everyone will have their first high-pressure procedure in a high-acuity patient one day (e.g. cricothyrotomy, thoracotomy, pericardiocentesis, etc.) and – speaking from experience – deliberate mental rehearsal can reinforce the necessary steps and significantly reduce the stress associated with these encounters. When I come in with my CICO airway nightmare, I want the resident that daydreams about managing the stresses of high-acuity procedures and visualizing their cric technique to be holding the scalpel.

The Mental Model (a.k.a. Mind Map)

In order to promote the development of a more robust understanding of the concepts relevant to these cases, I also encourage learners to take every case to the “end of the algorithm.” For example, the pediatric asthma patient in your mental emergency department does not get better with nebs and steroids, and the lower GI bleed does not stop after FFP. Every case should be run through its “worst case scenario” to ensure the learner has a mental model that includes the full spectrum of disease, to review the required knowledge for managing decompensation (e.g. intubation equipment sizes, ventilator settings, timing of IR consultation), and again to provide that mental rehearsal which allows for a level of familiarity when refractory cases present in real life.

Applications

As an early attending, I still use this technique to study. I’ll even test my mental models on shift by imagining the possible pathways of decompensation for patients in the department. While this may sound a bit morbid, it’s nice to have already run through the worst-case scenario in your mind whenever a patient does decompensate – at that point it simply becomes a matter of executing your existing plan.

Closing Thoughts

Someone once described emergency medicine to me as a “specialty of preparedness,” and I couldn’t agree more. I’ve found this technique of rigorous mental rehearsal extraordinarily helpful in developing my practice, improving both my cognitive and emotional preparedness for high-acuity encounters. I’m sure many others use similar techniques; however, in the case that you have not, I would encourage giving it a try. The peace of mind that comes along with the preparedness of having already mentally worked though the stuff of nightmares is invaluable.