Mental Practice For Uncommon Emergencies – Great Help From Dr. Morganstern Of First10EM

Emergency procedures (perimortem C-Section* and pediatric emergency rapid sequence intubation, for example) and emergency management of life threatening illnesses (management of severe croup*, respiratory distress in a trach patient*, and management of life-threatening asthma*) are rare even for emergency medicine specialists.

*These four posts are from First10EM and can be used as scripts for mental practice.

And for clinicians (primary care practioners, nurses, and paramedics) practicing in areas served by critical access hospitals these life-threatening problems are even rarer.

To stay prepared for these rare emergencies Dr. Morganstern, of First10EM, has written an oustanding post: Performance under pressure, mental practice and how to use First10EM. You need to carefully read the whole post [This is a note to myself].

All that follows is from Dr. Morganstern’s post:

I think First10EM is best thought of as a guide for mental practice. The posts may teach you something if read once. But to truly benefit – to ensure that you will be able to manage those first 10 minutes of extreme pressure – these posts should be seen as a framework to be adapted to suit your own skills and the resources available to you, and then reviewed repeatedly until the skills become automatic. Then you can be sure that you will be ready, no matter what comes through the door next. [Emphasis added]

I started this blog having never heard of ‘mental practice’. It was just something that I did; something that made sense to me. It turns out, mental rehearsal is actually supported by some evidence. Today’s post is a brief review of our performance under pressure, mental practice, and how I think First10EM is best used.

What is mental practice? There are a number of different definitions, but the essence seems to be cognitive rehearsal of a specific skill without physical movement. . . . The lack of movement, for me, just means you aren’t physically performing the task you are practicing.

In medicine, mental practice has been shown to enhance surgical and procedural skills. (Arora 2011, Komesu 2009, Sanders 2004, Sanders 2008) More recently, mental practice was also shown to improve performance in team based trauma resuscitation simulations.

Mental practice is cheap, easy, and can be done basically anywhere and anytime. I want to make sure I always have the resources I need to meet the demands of emergency medicine, and mental practice works for me. First10EM exists because I hope it will work for you as well.

So how does this mental practice stuff work? How do I use First10EM?

The core content of First10EM is a series of approaches to life threatening presentations in emergency medicine. The blog posts represent what I think is the best approach – after reviewing multiple textbooks, publications, and FOAM resources – for me, considering my skills and the resources available to me at my hospital. The approaches I publish are not meant to be universal. They are guides. Hopefully, they are useful, but to be used properly, they should be adapted to your own skills and setting.

Mental practice is different that just reading and trying to commit facts to memory. It involves setting the scene in my mind; imagining not just the patient, but my actual resuscitation room and the other people in that room. For each step in my approach, I picture how I will make it happen. If the asthmatic patient needs oxygen, bronchodilators, an IV, and to be placed on the monitors, I specifically think about who is going to do what, and in what order. (I can take care of the monitors, while my nurse starts an IV, and my RT looks after the nebulizer and oxygen.) If I need to start BiPAP, I know our machines are stored in a different hallway, and I will have to send my RT away to get one. I rehearse that timing. If I plan to perform a finger thoracostomy to deal a pneumothorax, I actually picture where in the resuscitation room we store scalpels and chlorhexidine, and exactly where and how I will make the cut. The blog posts guide me through this practice session, and provide a simple frame that helps me to mentally organize my approach, but I think the real value comes from the mental simulation.

This sounds like a lot of work, and honestly, the first time you try it, mental practice can be time consuming. However, each practice session becomes quicker and more efficient. When I started, I was usually sitting quietly, doing nothing other than running through the scene in my head, but eventually it becomes second nature, and you can practice skills while driving to work.

I have noticed other benefits as well. Quite frequently, when mentally practicing for emergencies, you will notice some deficiency in your own skills or your department’s set-up. When reviewing how to deal with shoulder dystocia, I realized I didn’t know where our department stored obstetric equipment. The nurses probably would have been able to help, but what if I am working with a new nurse the day I need it? At the start of my next shift, I found the equipment, and can now get it for myself if whenever needed. When practicing my approach to local anesthetic toxicity, I discovered that our department did not stock intralipid. It was in the pharmacy, a minimum of 30 minutes away. Now it’s in our resuscitation area.

Although this is often thought of as an individual exercise, I find it also works well in groups. Many people have experience the “what if” teaching method – what if you can’t see the cords, what if there is blood in the airway, what if the bougie will pass but the ETT won’t? Thinking through these scenarios is an important form of mental practice that can be done as part of bedside teaching. This also works in small group seminars – rather than simply lecture, have the group think through the steps of management, and really focus on the logistics of getting things done.

See also the great Notes (references) in the post.




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