Page 32 - JSOM Fall 2022

skill execution, is the individual’s degree of constructed automa­ On occasion, instructors have had trainees practice life­ saving
1­4
ticity (commonly referred to as “muscle memory”), fidelity of combat skills with live gunfire, live explosions, or other noisy
5­8
his or her mental representation of the task, and the ability distractions in close proximity. Although the intention of
to pattern­match and recognize indications or obstacles to task training techniques such as these is to get students conditioned
completion. 9,10 For example, inexperienced or novice medics to working with distractions, these modalities may have unin­
may have never placed a tourniquet on a real patient. As such, tended consequences. Situational awareness is the perception
they have to use more cognitive resources to control their atten­ of the elements in the environment within a volume of time
tion, think about executing the correct steps of the procedure, and space, the comprehension of their meaning, and the pro­
33
and consider any challenges or difficulties with the procedure. jection of their status into the near future. Expert medics, or
The addition of extrinsic stressors such as yelling, gunfire, or even those with some experience, might recognize the sound of
direct disruption of the activity from an instructor can create close and effective gunfire, understand its significance, recog­
34
an overly stressful environment for students who have not yet nize they are in a Care Under Fire situation, 35,36 and take ap­
developed competence with certain skills. propriate action (e.g., identify threats, immediately return fire,
take cover, instruct the casualty to return fire if combat effec­
Although training to manage the stress of combat, in general, tive). 36­38 Novices are easily overwhelmed by stimuli, may not
is a reasonable and potentially helpful paradigm, it may not be able to gather or recognize critical data, understand what
39
be useful when it comes to the initial acquisition of funda­ it means, and formulate the appropriate response. Instruc­
mental technical skills. Stress is a process whereby environ­ tors do a disservice by training individuals to ignore potential
mental demands evoke an appraisal mechanism in which dangers (e.g., gunfire in close proximity) that should prompt
perceived demand exceeds available physical and mental re­ critical actions (i.e., tourniquet application and returning fire)
sources, resulting in undesirable physiological, psychological, and instead have them pack wounds, perform needle decom­
and behavioral outcomes. 11,12 This does not always facilitate pression, or conduct endotracheal intubation (skills that are
effective learning. A stressor that activates the hypothalamic­ not part of Care Under Fire. The response to a dangerous stim­
pituitary­adrenal axis is moderate, germane, and specific to the ulus is extinguished, and development of effective situational
task at hand during an educational activity (e.g., the intrinsic awareness is hindered. This may be counterproductive in situ­
stress of applying a tourniquet with ongoing simulated hem­ ations of real­world combat or imminent danger, where a keen
orrhage) and may be helpful for learning. Specifically, there sense of situational awareness is necessary for survival. 40­42
may be enhanced memory consolidation and future retrieval This concept needs to be thoroughly understood and taught
of information. 13­16 However, stressors that are not directly re­ to instructors. Instructors need to know their students’ level of
lated to learning goals (e.g., extrinsic stressors) or severe stress experience and adjust their training techniques appropriately.
can have the opposite effect. These stressors detract from
the brain’s ability to store information in long­term memory, When Adding Stress and Complexity Is Beneficial
which has a negative effect on a learner’s capacity to recall Immunizing trainees to harsh and stressful environments in
information and apply it in the future when needed. 13,17,18 which imminent danger exists is certainly reasonable, although
even advocates of these training techniques strongly recom­
Ultimately, the goal for technical skill development in TCCC, mend they be incorporated into a more comprehensive, mea­
TECC, and STB is to be able to reproduce skills quickly and sured framework—and only after core skill development has
efficiently when someone is seriously injured in a stressful situ­ taken place. 43–45 This follows the tried­and­true, stepwise crawl­
ation. This occurs best when an individual develops automatic­ walk­run approach to building strong fundamental skills.
ity of a particular skill. Automatic psychomotor skills require
substantially fewer mental resources and are reliably repro­ SET is a comprehensive, multifaceted training model adapted
duced during periods of high cognitive load (such as when one in various forms by different military units, NASA, and
experiences significant stress). 2,19­21 Ingraining and automating other high­risk organizations to train individuals in domain­
the correct psychomotor program is critical. This requires ap­ specific skills and gradually expose them to increasing levels
plication of novel information and retrieval of knowledge from of stress. 43–45 The goals of this training are to gain knowledge
memory. Therefore, if a trainee was taught during a didactic of and familiarity with a stressful environment, to develop and
session where to place a tourniquet in relation to an injury and practice task­specific skills (including various psychological
how best to tighten the tourniquet, he or she would have to skills) as well as decision­making faculties to be performed
retrieve this information and apply it. However, stress can also under stress, and to build confidence in an individual’s capa­
inhibit effective information retrieval. 13,18,22,23 Furthermore, ex­ bilities. When properly adapted in different environments, the
cessive stress seems to switch the system’s underlying learning technique has demonstrated notable improvements in perfor­
and memory from a more “cognitive” memory system in the mance: improved examination scores, response time to per­
hippocampus to a more rigid “habit” memory encoded in the form technical skills, and accuracy of complex flight skills. 43­48
46
dorsal striatum. 24­28 This switch results in cognitive persever­ Saunders et al conducted an extensive meta­analysis evalu­
ation: continuing or repeating a given action or plan that one ating the data showing the various benefits of SET in various
has recently used or previously applied. As stress increases and military and civilian domains.
cognitive faculties deteriorate, individuals may continue try­
44
ing the same unsuccessful solution despite clear evidence of its Originally proposed by Driskell and Johnston, SET takes a
failure. 29,30 They default to what is known or familiar in times modified approach using three phases:
of stress. 31,32 Unfortunately, when trying to apply new infor­
mation or solve a novel problem, trainees might fail to explore • Phase One: Information provision. This phase provides in­
novel solutions, apply learned information, and develop ef­ formation on the human stress response, conditions partic­
fective technical skills. Thus, overly stressful drills potentially ipants on what they should expect to encounter, and other
reinforce old, bad habits and perpetuate incorrect techniques. preparatory information.

30 | JSOM Volume 22, Edition 3 / Fall 2022