Page 56 - JSOM Spring 2023

Emergency Reflex Action Drills and
the Problem with Stress

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Natalie Zink, BS *; Andrew Merelman, DO ;
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Andrew D. Fisher, MD, MPAS ; Michael Lauria, MD 5

ABSTRACT
Clinicians involved in the care of critically ill patients are of- selectivity,” a tendency to lose global situational awareness
ten exposed to demanding and stressful situations that require and to focus on particular tasks. Noise, visual interference,
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immediate action. Evidence suggests that human performance or time constraints are major contributors. Furthermore,
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can be significantly diminished when multiple stressors and stress causes impaired prioritization of information. Evidence
stimuli are present. Humans have developed conscious and suggests individuals focus on what is perceived to be most im-
unconscious methods of dealing with this type of cognitive portant, but the stimulus that commands our attention might
overload in various high-risk occupations, but these coping not be the most critical to actually solving the clinical puzzle
methods have not necessarily been structured and adapted to presented. Therefore, the fewer pieces of information we must
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the provision of emergency medical care. Emergency reflex process, the lower the cognitive load and the lesser the narrow-
action drills (ERADs) are derived from available evidence in ing effect. 9
specific domains (e.g., airway management) and develop auto-
maticity of critical skills which engender quick, effective, and These effects are compounded by the tendency to revert to
reproducible performance with minimal cognitive load. These a more recently or more regularly used response to a situa-
are pre-planned, practiced responses to specific, high-demand tion. 10,11 Increasing stress combined with a decrease in deci-
and time-sensitive situations. This article outlines the psycho- sional capacity means people will continue repeating actions
logical, cognitive, and behavioral effects of stress that affect despite their continued lack of success. 12,13 Cognitive psychol-
performance and necessitate development of ERADs. It also ogists have suggested this aligns with current understanding
reviews the scientific underpinnings behind how humans of human behavior under stress: the tendency to default to
have adapted cognitive behavioral techniques to manage un- what is known or familiar. Because of this, during a cognitively
der high-stress situations. Finally, this article recommends the demanding and stressful situation, clinicians may not consider
adoption of these cognitive tactics via ERADs to enhance clin- or recall novel techniques or interventions that have demon-
ical practice and provides an example in the context of airway strated utility. 14–16
management.
Stress also decreases information processing and working
Keywords: adaption; error; performance; stress; training memory. 17–19 It affects internal dialogue (keeping informa-
tion available) and causes increased distraction. 20,21 Research
demonstrates that stress impairs complex problem-solving
and decision-making for obstacles that involve spatial visual-
Introduction
ization for a successful resolution. 22,23 Therefore, a provider’s
The Problem with Stress in Medical Emergencies ability to perform clinically important cognitive tasks (such
Clinicians involved in the care of critically ill patients are ex- as thinking about the underlying pathological process) is hin-
posed to extremely demanding and stressful situations, espe- dered and takes more time.
cially when immediate action is required. In fact, management
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of high acuity patients can be classified as “crisis situations,” Finally, these effects have specific implications for clinicians
defined as circumstances rife with uncertainty, clear and pres- inside and outside of the hospital. The dynamic nature of
ent danger to life, the need to take immediate action, and at practice makes them uniquely prone to these cognitive se-
least partial inability to control the situation. The stress expe- quelae, resulting in mistakes and medical error. While many
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rienced in these situations can compromise a provider’s ability authors discuss the complexities of general diagnostic errors
to perform at their best which may affect patient outcomes. or medication errors, few have identified errors involved in
common emergency procedures. 25–29 For example, providers
The effects of stress on memory, cognition, and technical can lose situational awareness during endotracheal intubation.
skills performance have been documented across different do- Cemalovic et al. found that emergency physicians’ perception
mains. One such effect is attentional narrowing. The field of of time to intubation was significantly skewed, believing they
engineering psychology has referred to this issue as “increased were much faster. Possibly more concerning was the fact that
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*Correspondence to nzink@augusta.edu
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1 Natalie Zink is affiliated with the Medical College of Georgia, Augusta, GA. Dr Andrew Merelman and Dr Michael Lauria are physicians
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affiliated with the Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM. Dr Andrew D. Fisher
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is a physician affiliated with the Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, and the Texas Army
Natonal Guard, Austin, TX.
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