In medicine, we often draw some of our lessons on safety from the aviation industry (i.e.: preoperative checklists), here we will explore a host of pearls that medicine can learn from the brilliant minds at NASA to help augment one’s practice as an expert clinician.
Commander Chris Hadfield has previously discussed a riveting tale regarding his first ever space walk1. During his mission, he was tasked with helping to assemble the Canada 2 space arm on the International Space Station (ISS). While outside the ISS, he developed some stinging and burning in his eyes (from the cleaning solution he used on his visor), and was essentially blind in space.
In a setting like this, it is easy to image a vast majority of people would lose their cool – but not a well trained astronaut, who deftly navigated the situation. An excellent comparison to this situation comes from Hadfield himself – who suggests that if you were to walk into a spider web, the natural reaction is to recoil in terror. However, if you were informed and educated to the point where you knew no poisonous spider could reside in that web, and you practiced walking into webs thousands of time – walking into a web would evoke no response. He likens this to his time being blind in space – that he was so well trained and prepared for every eventually that he had an approach to this particular problem. Hadfield remarks that “there is no problem so bad that you can’t make it worse”, which parallels the complexity and pressure of dealing with acutely unwell patients, and Crisis Resource Management (CRM) skills.
NASA is constantly thinking about various outcomes, and what they would do if ‘x’ or ‘y’ occurred. This preparation is what makes them so successful in the performance of their jobs and missions. A good physician will frame their thought processes similarly, and will anticipate outcomes and any necessary reactions or undertakings. Most physicians do this on a superficial level (i.e.: if the troponin comes back normal, or abnormal – a disposition is made). However, the expert clinician does this on a much deeper level. For example, hearing that a patient is involved in an MVC and is hypotensive, having a pelvic sheet on the bed before the patient arrives in the trauma bay, can allow for rapid and quick binding of the pelvis, or calling for a massive transfusion before it is necessary. It can also be done on a less dramatic level, I find when learners often struggle with their disposition/decision making it is because they’re not anticipating the results of their testing before it is completed. Before undertaking a test, one should anticipate all possible outcomes, and the subsequent reaction/next steps. Shaping your mental framework to anticipate things before they happen, will allow one to take steps forward to becoming an expert clinician.
Actions per hour
NASA ensures that astronauts have a very structured schedule while they are in space, having very limited time – they want to optimize the number of things they are able to achieve while they are away from Earth1. This brings forward the idea of ‘actions per hour’ (a term I have modified from professional video gamers, whom discuss actions per minute to increase their skills2). For me, the idea of actions per hour is a ‘flow hack’ to improve speed and efficiency in the ED. When one wants to enhance their productivity – one of the key things is to increase the actionable items that they can complete within an hour and to be cognitive of this. For example, when you have a moment of downtime between seeing a patient or reviewing with a learner, instead of checking for bloodwork that isn’t finished yet (or checking your email), complete a task that you know you will need to do, i.e.: the cardiology referral form, or TIA study sheet. Doing this consciously will enhance your actions per hour, and allow you to increase productivity and flow.
In his book1, Commander Hadfield talks about the constant repetition and training for every potential outcome during a space mission. In essence, Hadfield suggests that if you anticipate and prepare for anything, when it does occur, you have an approach and are able to handle it. This highlights the utilization of simulation in medical training, and continued medical education. It is through simulation that we are able to train for rare diseases, presentations, complications and procedures.
Medical trainees benefit from simulation, to expose them to diseases and presentations that they may not have learned in their training thus far. Additionally, simulation allows them to work on their CRM and leadership skills. After residency, however, physicians tend to fall into old familiar patterns, become stagnant in terms of their dynamic learning – and lose many of these skills that they had developed. This issue can be addressed by the use of staff physician mediated simulation, or in situ simulation in the ED. While physicians may loathe the idea of additional training, it is clearly evident that this will enhance their practice, skill set, and ensure that they are capable of handling complex and seemingly novel presentations.
There is a plethora of emerging evidence that individuals tend to perform worse under times of stress – regardless of what the activity is3,4. Performance in medicine is certainly no different to this – recall the first time you intubated, or placed a central line. The stress caused you to be tachycardic, tremulous and diaphoretic; all of which decrease your ability to perform effectively. NASA intentionally stress inoculates their astronauts, to ensure that when a unexpected or stressful event occurs, the astronauts have their full and complete cognitive and physical facilities at hand to complete their task1.
We do know that we tend to be less stressed/anxious after having successfully completed a task multiple times (i.e.: the anxiety of intubating begins to dissipate with each successful tube). Simulation once again provides an opportunity for stress inoculation in a safe and structured environment. Further to this, the introduction of stress inoculation to residents and training programs enhances performance and learner skill sets5. A good primer to more information on stress inoculation, has been previously been discussed with expertise on EMCrit.
In medicine, we often place a huge emphasis on training – and once residency is done, we tend to sit back, absorb less CME and stay set in our ways of practice. With astronauts, once they are selected to go into space (akin to completing residency), that is when the real hard work, training, and repetition begins. In medicine, if we adopt a fraction of this thinking we can certainly better our clinical practice, be better physicians and enhance care for our patients.