Hack Your Brains - In Advance

A few years ago, I read Blink: The Power of Thinking Without Thinking, by Malcolm Gladwell (Little, Brown & Company, 2005).  At the time, the book struck a chord with me.  The main concept explains how people, especially experts, can tell at a glance what is going on and make accurate decisions.  Gladwell shares examples of this, including art experts who immediately know a statue is a forgery, psychologists who can tell if a marriage will break up in three minutes, and another psychologist who can understand microexpressions.  Experts do this by “thin slicing” available information, using relevant data quickly and discarding the other, useless parts of the whole picture.  The ability is affected, Gladwell explains, by other brain hacks such as priming.  The main point is that clear thinking can be overwhelmed by irrelevant information, and experts learn to ignore irrelevant information and trust their intuition.

This appealed to me because I had seen this way of thinking in action.  I’ve seen paramedics glance at a patient and know what was wrong within 5 seconds.  I’ve seen firefighters subconsciously know a roof was unstable, without being able to specifically explain why in a reasonable way.  I’d seen doctors know when a patient was hiding relevant parts of their story.  As an expert in EMS, it appealed to my self-image to imagine I could consistently do this.

The problem with Blink is that expert-level knowledge is required for successful thin slicing.  John Gottman, the psychologist who could predict divorce at a 90% success rate after three minutes of watching a video of a couple’s interactions, used extensive science, methodology built up over the course of years, and reason to be able to do the trick.  Paul Eckman’s microexpression Facial Action Coding System doesn’t use thin slicing – the system fills a 500-page binder.  Another problem is that incorrect thin slicing happens all the time and leads to dreadful outcomes.  It could be argued that some police shootings of unarmed people are examples of horrifyingly incorrect thin slicing.  The third issue with the book is Gladwell doesn’t explain how this works or how to improve the reader’s ability to perform this skill.  How does an expert mind accomplish what a novice mind cannot? 

Finally, I have a “Moneyball problem” with the ability of experts to consistently make accurate intuitive decisions.  If experts were especially accurate, then baseball scouts (experts) wouldn’t need statisticians (non-experts relying on data) in baseball player evaluations.  Slower decisions based on reasoning and data can be as strong as blinking out an intuitive answer.  When I first read the book, I intuitively loved it.  After further reflection, I think Gladwell’s Blink is probably an example of reporting bias – include the hits and don’t mention the misses.

Blink popped back into my mind because I finished reading Thinking, Fast and Slow by Daniel Kahneman (Farmer, Straus and Girous, 2011).  Kahneman and his late collaborator, Amos Tversky, are/were psychologists who specialized in investigating why people don’t always act in ways that rationality would dictate they should.  There is an imaginary creature, Homo economicus, which is used as a model in economic discussions.  This creature always acts perfectly to enhance its interests and economists can model the behavior.  People don’t act perfectly in their own interests, however.  Studying why they didn’t led Kahneman to win a Nobel Prize in 2002.  In economics.  He is a psychologist.  Badass.  (Tversky would probably have won too, but you have to be alive to win a Nobel.)

Thinking, Fast and Slow explains how the brain works with two systems.  System 1* is the intuitive cognitive system.  It makes snap judgments.  System 1 is effortless and automatic.  2+2=___.  Black and ______.  System 1 gave you those answers.  System 1 is also affected by emotion and associating images together.  When you associate a song with a specific time in your life, or a smell with a specific location, it is probably System 1 at work.  System 1 is the most common use of the brain.  Expert use of System 1 is what Blink was talking about.

System 2, in contrast, is the conscious, thinking, rational mind.  It is the system used to figure out 24x37=_____.    System 2 can read a map.  System 2 solves big problems in a rational, logical way.  The problem is System 2 is slow and lazy.  If you don’t force System 2 to work, it won’t.  As proof, I offer the fact that most of you didn’t expend the effort to find out 24x37=888. 

Too much data!  System 2 is out! Source

Here is the problem.  System 1 is often wrong.  System 1 makes bad decisions.  System 2 is pretty much consistently right, but is lazy and hard to turn on consistently.  Think about buying a car: You can figure out the prices, spreadsheet payments, work out pros and cons of models, and work out which is the best car.  But System 1 deeply and truly likes the red one.  People end up buying the red one.  Corporations prey on System 1 all the time in advertising.  Las Vegas is built on System 1 thinking (“This machine is about to get HOT!”).

You can almost see the spot that is missing System 2... Source

Why is this on an EMS blog?  Because System 1 has problems providing consistently good medical care.  When a drip rate calculation is needed, you turn to System 2.  System 2 yawns at you and rolls its eyes.  System 1 waves its arms above its head and says, “Oooh, oooh!  I know!  I know!”  System 1’s idea is to simply turn the drip on for a while to get the desired effect and system 2 can figure out the drip rate later when we are writing the PCR. 

System 1 freaks out at MCIs.  System 1 causes us to work dead people who should be pronounced.  System 1 causes us to skip the secondary because the patient smells bad.  System 1 finds a homeless guy in an alley and “thin slices” that he is just drunk, rather than checking other reasons for altered mental status.  System 1 is where errors happen.  So what can we do to strengthen System 2 in our professional lives?  It doesn’t work to say: “I will try harder.”

To me, the trick to activating System 2 is to turn 2 into 1.  Make your rational, reasoned, calculated decisions into intuitive ones.  We do this by working them out in advance.  This is the strength behind preplans, SOPs, and protocols.  Exercises prime System 1 actions through advance System 2 work, as well.  Practicing rare events until our actions become instinctive is switching System 2 thinking into System 1 thinking. 

It is also important for protocols and SOPs to not rely on System 2 thinking.  Protocol authors should strive to get rid of the potential for error.  Require less thought.  Don’t let System 2 yawn and roll its lazy eyes when you need it to work.  For example, my treatment protocols don’t call for drip rate calculations anymore.  Take epi: my protocols call for 1 milligram of any concentration of epinephrine into a liter bag of saline, run wide open and titrated to effect.  In advance I know the concentration of epi in the liter bag is 1 microgram per milliliter (System 2).  But I don’t need to think through it when with a sick patient on a drip.  I need to inject the med and open the line (System 1). 

Airline pilots don’t rely on their memories when using checklists and emergency procedures.  They pull out a book.  Trying to rack your memory for the emergency procedure while in the emergency is calling on System 2.  Having your copilot read the pertinent list of actions is using System 1.  This is also the idea behind the Handtevy pediatric treatment system – figure it all out in advance and then look it up.  Don’t change your treatments between adult patients and pediatric patients; simply open a book and look up the smaller doses.  Switch System 2 thought processes to System 1 thought processes.  We know adult treatments so well that we are working in System 1 when we are treating adult patients.  Pediatric patients, especially sick ones, freak us out and we didn’t memorize all the dosages well enough to cut through the fog.  The need to recall pediatric treatments fall on System 2.  Don’t depend on System 2 for your success.  Switch 2 for 1 and get to work.

Take the time to recognize where system mistakes occur and fix them in advance.  Make your job simpler, so you don’t need to rely on System 2 while under pressure.  Don't get me wrong - System 2 is not the problem.  Don’t get me wrong.  System 2 is what allows us to calculate the trajectory of a probe we’re shooting at Pluto, after all.  But take the strengths of System 1, especially the speed of System 1, and combine that with the strengths of System 2.  You do that by working out your actions in advance.

*Yeah, I wish he had come up with more descriptive system names, too…

Interview Fail

Years and years ago, at the beginning of my career, I was looking for my long-term EMS job. I applied at a private ambulance company that did all the 911 transports for a large city in a different state. It was a big enough city to be busy, with plenty of gory EMS calls and "fun" situations, but also offered suburban response for slow days. There should be plenty of calls and an agreeable climate for me. It seemed like a good place to work. I received word that the application process would continue with a four-day process of testing and evaluation. I got myself a cheap plane ticket and a crappy hotel room and began their hiring process. 

Day one consisted of a written test of the applicants’ didactic knowledge. I have to say, I rocked that. I was about six months out of paramedic school and had just recently passed the initial National Registry test. So I was primed and thought this agency’s test was reasonably easy. They put a six-hour cap on taking the test, but I finished in about an hour. I was nervous - maybe I missed something and got done too soon. So I checked my work. It all looked good, so I stood up to submit it. The test proctor was unimpressed: “You can’t be done yet.”

“I’m done.”

“Nobody gets done that fast. You understand that when I put the test into this machine for grading, it is finished. You can’t retake it…”

“I’m done,” I told him.

He shook his head with pity and put the bubble test answer key into the grading machine. It clicked a few times and spit out my score: 93%. The proctor didn’t offer comment, compliment, or apology. Not even a raised eyebrow. Jerk. Anyway, I was to come back the next day for some scenarios. One whole day down and it only took me an hour.  

On my way out, I got the chance to ask a medic about the job and the company. “How many ambulances do you run for the city?” I asked.

“Forty.” He was a man of few words, apparently.

I clarified my question. “No, no. Not how many physical vehicles the company has. How many ambulances are staffed and out in the city running calls right now?”

“Four. Tee.” The helpful gent told me emphatically before walking away.

That seemed wrong to me. That city was a little smaller than Denver, and Denver was an EMS system that I was vaguely familiar with. Denver ran 12-15 ambulances at any given time. How could this slightly-smaller city be running forty? It didn’t make sense to me.

I spent the rest of the day relaxing. It looked nothing like this. Unfortunately.
(Public domain; Source)

The next day, I showed up at my appointed time to run a few scenarios. I walked into a room with a plastic dummy on the floor.  Behind a table sat three medics. Another medic stood with a piece of paper.* The first scenario was a forgettable medical scenario. It was really vague; the patient was weak and dizzy in a low-grade sort of way, but there wasn’t a whole lot else going on. The vitals were normal, the ECG was normal, and so on. It was just a vague, low-grade, everyday medical call. I think I imagined myself to start an imaginary IV and took the imaginary patient to the imaginary hospital.

“Alright, the scenario is done,” one of the medics told me.  “What do you think was going on with that patient?”

“I don’t know, specifically.” I told him. “It could be anything.” I started to run through a list of medical diagnoses. 

The medic stopped me. “It was an obvious cardiac patient,” he told me, kind of contemptuously.

Weird, I thought. Cardiac patients must present completely differently here. There was absolutely nothing obviously cardiac-related about the scenario.

The next scenario had the same set-up, with three dudes behind a table and a guy with a piece of paper. There was nobody else in the room, though. The proctor told me that I had responded to a shooting. I asked him where the patient was. He said the cops had him in the next room, but they were on the way. So I stood there and waited.

And waited. For about a solid minute, I stood there and stared at the graders. They stared back. Finally, a pretend-cop and pretend-patient walked into the room. As the patient approached, I lifted his shirt. A piece of tape over his xyphoid said “bullet hole.” I told him to keep walking and get into the imaginary ambulance.

Continuing with the scenario, I cut the patient’s clothing off, performed a full secondary exam, and put a non-rebreather mask on the patient. I also started two IVs. All of that was imaginary, of course. Anyway, we were off to the imaginary hospital. Enroute, I reassessed the patient and found him to be experiencing increasing dyspnea with absent breath sounds on the left. I needled his chest. The patient briefly improved, but began to decompensate quickly and become somnolent. I told the proctor that I would nasally intubate the patient. 

“You’ll what?” he asked me. I repeated myself.

“Just like that. You’re just going to go ahead and nasally intubate him. Yeah, right...” he said sarcastically, rolling his eyes and exchanging smirks with the graders behind the table. 

“Yep.” I said with a smile, thinking that with two rolls of Kerlix and a seven-oh tube I could intubate him where he stood. See if he still smirked then. But they decided to let the intubation stand. That was about it. There wasn’t a whole lot else to the scenario.

Afterwards, I was advised that I failed the trauma scenario and would have to repeat it after lunch. Apparently, the failing criteria were that I didn’t go fetch the patient, I let him walk, I didn’t immobilize him, I didn’t check a sugar, I didn’t use an ECG, and I didn’t use a pulse oximeter. I was flabbergasted. One of the failing criteria was that I didn't check a blood glucose on a shot patient? What kind of place was this?!?

I decided it was a kind of place that wasn’t for me. Beyond the rude employees, which I can overlook, the medicine didn't seem to align with my professional ethic. I thanked the guy who had just explained my failures and left. I never returned. I enjoyed two more days of solo vacation and returned home. About a month later, I got my current job. Things worked out for me. I’m glad I wasn’t in a position where I had to take that job, just for the sake of getting paid. 

There is a job out there that is perfect for each of us. Hopefully you are in a position to find yours instead of settling.

*He was the "voice of the EMS gods."  All scenarios are crap because you need a voice of the EMS gods. The voice is the person who answers when you grab a wrist and ask for a pulse rate, out loud. “One hundred.” 
“What does his skin look like?” The voice of the EMS gods answers: “Pink and dry…”

Where's Your Backup?

I remember the first time I transported an injured police officer. I was a new EMT, working with an experienced paramedic partner. The local police had tried to arrest a gentleman who didn’t want to be arrested. The conflicting desires of the police and the accused felon resulted in the initiation of a vehicle pursuit. (It was long enough ago that cops still did such things.) The car chase ended with a crash and short foot pursuit. During the vehicle pursuit, though, one of the police cruisers was involved in a separate frontal impact crash. The officer, being a police officer and knowing many car chases end with foot pursuits, was unrestrained in preparation for jumping out of his car and running. During his crash he hit his head on the windshield. He had a little forehead hematoma/abrasion and the windshield was starred, but the officer denied loss of consciousness and neck pain. As a matter of fact, he didn’t especially want to spend the rest of his day at the emergency department and sincerely did not want an ambulance to take him there. His sergeant essentially told him to shut up and forced him into the ambulance.

In the ambulance, the officer sat on the bench seat and my partner began disrobing him. (I remember thinking that police officers are much smaller people without all of the paraphernalia. Cops look like normal people; their vests and belts make them look fatter more buff.) He gave the officer’s uniform shirt, ballistic vest, and duty belt to the sergeant. The sergeant would take care of all his possessions, including the officer’s firearm. I put a backboard onto the bed (see – the call was a long time ago) and we moved the officer onto it. My partner had assured himself that Bill the New EMT could attend and moved to exit the ambulance. Before he did, he asked the officer: “Wait. Where’s your backup?” 

I thought he was talking to me, which was confusing. Why do I need backup with so many cops on scene? But the officer knew what he was being asked. He lifted his right foot off the backboard and shook it. My partner lifted his pant leg and removed the dinky revolver from the ankle holster. It was a cute little thing, as I recall. “Anything else?” my partner asked. The officer denied having anything else. “No knives?No backup backups? Throwdowns? Last chance…” The police officer had nothing else on him, apparently. We took him to the hospital.

If an Apache revolver is your backup gun, you can keep it. I'm certainly not getting involved with it...
By Latente Flickr [CC BY-SA 2.0], via Wikimedia Commons    

The call itself was no big deal, and it was not an uncommon EMS call. Police officers get injured. What made it stick in my mind was the search for backups and the ensuing conversation. I asked my partner about it after the job was done. He patiently explained that officers carry knives, backup firearms, and assorted throwdowns. Many officers (and people in general) carry folding knives in their pockets or clipped somewhere on their person. They are tools, used for everything from opening mail and cleaning fingernails to cutting seatbelts and even (I suppose) last-ditch fighting. A backup weapon is an extra firearm that the sergeant probably knows about. Backups are commonly carried on ankle holsters or occasionally attached to ballistic vests. Not every officer carries a backup, but some do. 

My partner explained that when police officers become patients, they sort-of cease to be police officers. It’s not true, of course, but it works as a model to discuss. Patients shouldn’t be armed. Head injured patients definitely shouldn’t be armed. Mental status can change suddenly and without warning. It is not an unbelievable progression to go from head injury to short seizure to post-ictal confusion. The last thing we want to deal with is an armed police officer after s/he has suddenly become altered, frightened, and can easily reach their heater. The risk is small, but easily avoidable by giving all the police accoutrements to another cop. 

In addition, my partner continued, duty belts are uncomfortable in the back of an ambulance. Further, they interfere with immobilization. The same thing is true of vests – ballistic vests raise the torso slightly, causing the head to fall posteriorly slightly more than would usually occur when a patient lies supine in a vest. Both belts and vests should come off. The shirt has to come off in order to take the vest off. We could take shirts, vests, and belts to the hospital with us, but officers are usually more comfortable with other cops being in possession of those kinds of objects. So we give it all to another police officer. It used to be a good idea to repeat the backup weapon search when the officer’s supervisor wasn’t around, in case we needed to be subtle getting a secret throwdown piece to a fellow officer rather than the supe. But that has become a non-issue over the years.  

Finally, removing all of those police-type items gives the subconscious impression to the officer they they are temporarily not a cop for the moment. Taking off all the crap subconsciously feels like going off duty to the officer. By taking off their duty belt, they become a person. It is easier to make a person a patient than it is to make a tough-guy (or worse, tough-gal) officer a patient.

Oh. The situation had been well-thought out and made sense. I’ve followed the practice since. I love to adopt good ideas. I’m lucky. In my system this is expected, so I don't need to explain the process to injured officers. The officers, other uninjured officers on scene, and supervisors all know what should happen. Everyone is down with the plan. Occasionally I need to remind them, but I’ve not had to have long discussions or negotiations. This process would hold true for me in any system, though. Good ideas are good ideas.

My Ears

I had a weird thought this week: My stethoscope has been on every call that I have.

My stethoscope is apparently a badass salty street-dog. It has worked up trauma patients and medical patients, peds and geriatrics, helped to ascertain endotracheal tube placement, and auscultated thousands of blood pressures and breath sounds. My ears have worked up the patient in every one of my stories (including the stories I refuse to share in public). It has auscultated the sickest patients in the city and it has listened to the least sick patients ever needlessly transported to an emergency department. It has seen the calls that made me laugh, the ones that made cry, and the calls that made me want to scream. It has been in the bus during every crash I've been in. It watched me get stuck with needles, kicked, spit upon, and threatened. It also watched me be thanked, be hugged, be respected, and be laughed at. My stethoscope has listened to my chest and the chests of my family members. The only call my stethoscope hasn't seen is a lightning strike.

I roll with a Littmann Master Classic II that started out with grey tubing. It has the old-style head design - the newer models look a little different. Two years ago, I found out that Littmann will refurbish everything on a stethoscope that isn’t metal for about $50. My old friend needed it – the tubes had a big bite mark from a human molar (I’m still mad at that asshole), the diaphragm had been giving me problems, and the earpieces were held on with medical tape that I had colored black with a sharpie. But the grey tubing was no longer offered. So now I have a blue stethoscope. Still works awesome, the head kept all the dents and dings that decades of lifesaving gave it, and the right earpiece still isn't straight. It is still my 'scope.  

It has been in service on EMS calls since the mid-1990s. I’ve had my stethoscope for almost 20 years. Is that unusual? One video on YouTube suggests just using a filthy disposable set of ears because you are going to lose so many. At least, the guy in the video does. I think it may be like pens – I lose the ten-for-a-buck disposable pens constantly, but I have a few pens that cost a bit of money and kept track of them. Sunglasses work that way for me, as well. I don’t know; I’ve not lost my stethoscope. Do you lose stethoscopes often?

I know people think their coworkers steal them. That never made sense to me - people mark their 'scopes in secret but identifiable ways. If someone saw you using their stethoscope... Well, that would be ugly. There isn't a thriving black market for used stethoscopes. Speaking of seeing someone else use my stethoscope, it makes my skin crawl when someone asks to use my ears. Uh, no. Put someone else's earbuds into your grungy ears, not mine. It just happened last week, as a matter of fact, with a physician on scene of a public fainting call. She asked for my stethoscope and I laughed at her. 

Anything that has been with me that long deserves a name. Hell, I think I have known my stethoscope longer than I have known my wife. Longer than any partner. Longer than any job, or pair of boots, or flashlight, or pair of trauma shears.

If you don’t have your "career stethoscope" yet, there are a few websites to help you through the choice. This one is an extensive review of stethoscopes – it’s good, but overwhelming. I didn’t do that much research when I bought my car. This review actually likes the Sprague. (The only problems I have with the Sprague is that it is dual tube, which causes tube noise artifact, and the diaphragm doesn’t seal as well as I like, so funk can get behind it.) Here is another review and buying guide. I assume most readers have a pair of ears, so I’m not going to go through a how-to-buy guide. But you should definitely clean the crap out of your stethoscope on a regular basis.

Take care of your stethoscope. It is like investing in a career-long friend.