Copyright 2017 by Sea Courses Inc.

Transcription

1 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

2 already by 7:30 AM Shower/bath?? Brush your teeth - pre/post?? Coffee/tea - type?? Breakfast - what?? What to wear?? Transport to work?? Check social media which?? Dinner?? Exercise when?? Plans for evening?? ++??

3

4 Cognitive De-loading How to Conserve and Use Cortical ATP Efficiently

5 ognitive Resource Economics How to Conserve and Use Cortical ATP Efficiently

6 Learning Objectives Define the burden of cognitive loading in the emergency department. List ways in which the emergency medicine physician can manage cognitive exertion and exhaustion

7 Recognition importance of cognitive loading in decision making Describe combat decision fatigue Learning improve cognitive stamina -

8 Lack of exposure "When I was in medical school I spent hundreds of hours looking into a microscope a skill I never needed to know or ever use. Yet I didn't have a single class that taught me how to think, communicate or teamwork skills-something I need every day I walk into the hospital. Peter J. Pronovost, MD, PhD Sr. Vice President for Patient Safety and Quality, Director of the Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine

9 Metacognition Thinking about how we think

10 2016 Formal Rounds ~ < 5%

11 2016 SMACCDub ~ 40 %

12 Who? Why?

13 Why?

14 Diagnostic Error (ED) ~ 15% > 90%...error in decision making (vs. lack of knowledge/system/patient/etc )

15 Perfect Storm The Shi(f)t Load High diagnostic uncertainty Fatigue (shift work/sleep deprivation/ life ) High decision density decision fatigue

16

17

18

19

20

21 Casey Smith MD PhD CCFP FRCP FACEP.

22

23 . System 1 AND 2

24 23:20 Meetings all day Rushed to work late ++busy (NPO, nwc, ACLS x 1) Day-Night-(TODAY)-teaching day Phone call: Life Scheisse Challenging trainee Pissed off consultant Pissed off nurse

25 23:20 Meetings all day Rushed to work-late ++busy (NPO, WC) Phone call Challenging trainee Pissed off consultant Pissed off nurse

26 usual drunk in trauma bay ~40 male Bloodied shirt, homeless, intoxicated cursing Bloody nose, GCS no focality P110, BP 130/80, Sat 95% No other obvious trauma (E?)

27 23:20 Meetings all day Rushed to work-late ++busy (NPO, WC) Phone call Challenging trainee Pissed off consultant Pissed off nurse

28 let him sleep it off Allocation: corridor stretcher Work-up: Gluc normal

29 23:40 Meetings all day Rushed to work-late ++busy (NPO, WC) Phone call Challenging trainee Pissed off consultant Pissed off nurse

30 23:50 GTC x?minutes Rx: Midaz BP 80/-, P120, GCS E1,V1,M4 (P?) Rx: 2 L Rx Midaz

31

32 More DECISIONS After Dilantin? RSI how/who? Drop a line? where?...pressors? Sign out Meetings all day Rushed to work-late ++busy (NPO, WC) Phone call Challenging trainee Pissed off consultant Pissed Doctor.! off nurse

33 BP 60/- P 140 bagging hard fast Puke+++ suctioned RSI ETT IO placed norepi started 00:10 PEA arrest Rx: Epi, Ca, HCO3, NS, ECHO: no PCE Asystole, cardiac standstill

34 Post-Mortem Ac on Chr SDH herniation C 2 unstable # Rt. HTX/PTX (penetrating rt. ant. thoracic injury)

35 Post-Mortem - Decision Fatigue

36 M&M When a plane crashes, they ask, What happened? In medicine they ask: Whose fault was it? James Bagian, M.D. and former astronaut, Chief Patient Safety Officer and Director, National Center for Patient Safety, U.S. Department of Veterans Affairs

37 The great question is never how but why

38 Post-Mortem - Decision Fatigue

39 Decision fatigue aka cognitive loading every decision we make, no matter how important or unimportant, expends some of the limited pool of mental resources, until our ability to make decisions deteriorates. Roy F. Baumeister PhD, Professor of Psychology, Florida State University 2003

40 Not a new concept The more of the details of our daily life we can hand over to the effortless custody of automatism, the more our higher powers of mind will be set free for their own proper work. William James 1892 Father of American psychology/philosophy

41

42 Parole decision/antibiotic Rx Extraneous factors in judicial decisions P. Natl Acad Sci U S A Apr 26; 108(17): Time of Day and the Decision to Prescribe AntibioticsJAMA Intern Med Dec; 174(12):

43

44 Marketing 101 Making choices leads to reduced self-control (i.e., less physical stamina, task persistence in the face of failure, more procrastination, and less quality and quantity of arithmetic calculations)

45

46

47 Conscious decision making is DAMN expensive

48 DF high ATP usage End of shifts Handover High interruption density Sleep Debt/Sleep Deprivation

49 DF ATP depletion Decision avoidance Impulsivity (irrational choices) Impaired self-regulation

50 DF - Economics Conserve ATP Borrow ATP Make ATP

51

52 DF- Economics Conserve ATP Leave triviality to habit/end of day/garbage can Limit interruptions/eliminate all needless interruptions Cognitive Automatisms(int/ext) + know your stuff Decide and commit Stress inoculation

53 STRESS inoculation?

54

55 Mood Inoculation

56

57 DF- Economics Borrow ATP Delegate remember why YOU are there Consult

58 DF- Economics Make ATP Eat/drink Cognitive R&R Contentment

59 Cognitive R&R During shift Talk to Leave Outside Family/friends Rest (vacation/sabbatical) Hobby

60

61 already by 7:30 AM Shower/bath?? Brush your teeth - pre/post?? Coffee/tea - type?? Breakfast - what?? What to wear?? Transport to work?? Check social media which?? Dinner?? Exercise when?? Plans for evening??

62

63 0 risk MRI for all c spine injured all patients would be undergoing both cardiac catheterizations in addition to electrocardiographies when presenting with new chest pain for fear of undiagnosed myocardial infarction and we would indiscriminately admit every injured patient presenting to a Level 1 trauma center