EM:RAP COMMENTARY

Beyond ATLS: Demystifying the Expert

Resuscitationist
Steven Lai, MD*; Ashika Jain, MD; Jessica Mason, MD; Andrew Grock, MD
*Corresponding Author. E-mail: slai.emed@gmail.com.

0196-0644/$-see front matter

Copyright © 2018 by the American College of Emergency Physicians.
https://doi.org/10.1016/j.annemergmed.2018.07.021

SEE RELATED ARTICLE, P. 289. limited information. Even the black belts of resuscitation
medicine are stressed in these high-pressure scenarios.2-4
[Ann Emerg Med. 2018;72:299-301.] So how does an expert navigate the chaos, recognize the
pertinent information, and make quick decisions under
Editor’s Note: Annals has partnered with EM:RAP, enabling
our readers without subscriptions to EM:RAP to enjoy their
stress? In remembering yourself as an intern, it’s likely you
commentary on Annals publications. This article did not have already come a long way.
undergo peer review and may not reflect the view and What does it take to become an expert? There must be
opinions of the editorial board of Annals of Emergency repetitive exposure and constructive adaptation. In other
Medicine. There are no financial relationships or other words, learners must experience the scenario again and
consideration between Annals and EM:RAP, or its authors. again, each time learning from mistakes, adapting, and
improving. Through these experiences, learners improve
In pretty much every area, a hallmark of expert their awareness of the situation and become more efficient
and effective at anticipating what critical actions and pitfalls
performance is the ability to see patterns in a
collection of things that would seem random or might arise. This “spidey sense,” or “clinical gestalt,” that
expert resuscitationists tend to have may be unconscious.
confusing to people with less developed mental
representations. In other words, experts see the forest However, this “superpower” is deeply rooted in repeated
exposure to innumerable resuscitations and polished over
when everyone else sees only trees.1
—Anders Ericsson, PhD time by both reflection and analysis of their outcomes.5-7
These experiences form a network of automatic or
ANNALS CASE unconscious connections that permit experts to pick out
A 23-year-old woman involved in a high-speed motor subtle details and anticipate what might happen in the next
vehicle crash is 6 minutes away from the emergency few minutes, allowing them to always be a little bit ahead of
department. And, by the way, she’s hypotensive, has altered the action!
mental status, and has obvious trauma to her head, chest, Another way to explain the keen pattern recognition of
and abdomen. After the “Avengers assemble” experts is the idea of system 1 and system 2 cognition.
announcement, a team of nurses, technicians, and System 1 is intuitive and reflexive, involving rapidly making
physicians meets in the trauma bay to prepare for what is decisions based on unconscious pattern recognition. In
sure to be a complicated, high-pressure, high-stakes case. contrast, system 2 is analytical and problem solving,
Obviously, an expert resuscitationist is needed. If you aren’t requiring active critical thinking. This makes system 2
an expert yet, what can you do to get yourself there? This much slower and effortful.6,8
month’s article, “Getting Inside the Expert’s Head: An According to Croskerry and Norman9 (experts on
Analysis of Physician Cognitive Processes During Trauma experts!), “the effortless pattern recognition that
Resuscitations,” looks for some answers. characterizes the clinical acumen of the expert physician is
made possible by accretion of a vast experience (the
HOW DO YOU KNOW WHETHER YOU’RE AN repetitive use of System 2 analytic approach) that
EXPERT? eventually allows the process to devolve to an automatic
By nature, resuscitations are dynamic, complex, high- level.” Bottom line? Experts shift a lot of system 2 to system
stakes events. The high volume of stimuli is denser than a 1. With all that system 1 running in the background, the
gluten-free bran muffin. Decisions are made rapidly on mind of the expert is more available to detect subtle cues, as

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EM:RAP Commentary Lai et al

well as think more strategically and globally about the can also see the entirety of the situation, coordinate
resuscitation at hand.2,3,5,9-11 logistics, and ensure that critical actions are accomplished.
That position may be at the head of the bed or the foot of
WITH THIS IN MIND, HOW CAN ONE START TO the bed, or it may change during the resuscitation,
BECOME AN EXPERT RESUSCITATIONIST? according to the clinical scenario at hand.
As the article this month by White et al12 points out, Expert resuscitation team leaders avoid the mistake of
expert resuscitationists seem to have several specific, tunnel vision. Overfocus on a specific task prevents you
common traits they all share. Amid a chaotic resuscitation, from seeing the entire situation, and then important
they are keenly aware of how to get critical actions done, as information gets missed.
well as recognize and focus on the most important actions With experience, expert resuscitationists are able to
and stimuli. They are comfortable managing uncertainty recognize familiar patterns and develop cognitive shortcuts
and have the foresight to anticipate the next steps.3 For that filter rapidly incoming data and allow them to pay
your educational pleasure, we grouped these abilities into selective attention to high-yield information.5,8-11
the following stages of a resuscitation: foresight and Developing this skill can definitely be tricky. One strategy
planning, filter and synthesis of data, execution of plan, is to analyze where you focused your brain power during a
anticipation of contingencies, and after-event analysis. resuscitation. This can occur after the resuscitation in self-
reflection or in a debriefing with the team.
Another method to decrease these demands is cognitive
FORESIGHT AND PLANNING offloading. This can be done by delegating tasks and using
Expert resuscitation team leaders begin a successful external memory tools. Delegating tasks to a trusted team
resuscitation even before the patient arrives through mental member allows the team leader to focus on the whole
rehearsal. In their minds, they anticipate the clinical course, situation. For example, Dr. Banner secures the airway, Dr.
critical actions, and potential complications as they await Strange performs focused ultrasonography, and Mr. Stark
their patient’s arrival. Mental rehearsal as a group (ie, a obtains intravenous access. This allows the team leader to
huddle) can also boost team performance.13-16 focus on the entire situation instead of getting bogged
What is important to cover as a group? The team leader down in the myriad details.
may discuss role delegation, potential diagnoses, an initial External memory tools also help with cognitive
plan, and possible outcomes.2,3 Talking through these offloading. For example, the Broselow tape or telephone
things as a group decreases cognitive demand on applications provide precalculated weight- or age-based
individuals, and also helps to build trust and improve doses of medications and equipment sizes. Studies on
efficiency. Think of yourself as Captain America checklists from both anesthesia and emergency medicine
strategizing with the Avengers before a conflict. have suggested these cognitive aids reduce omissions,
Another potential pitfall is the gap between strategy (ie, reduce time to perform tasks, and improve
knowing the plan) and logistics (ie, knowing how the plan performance.17,18 Selective attention and cognitive
is executed).3 For example, you know you will need to offloading are invaluable tools to minimize the cognitive
intubate, but there is no intravenous access. You need to burden and mitigate the problem of high decision
provide bag-valve-mask ventilation for the patient while density.2,13
working on a line, preparing intubation medications for the Experts rely on unconscious processing of a slew of data
patient’s estimated weight, and preparing the airway to form impressions within seconds of seeing a patient.
equipment. All of this is done in the midst of the primary One pitfall is to completely rely on this instinctive process.
survey! There is both a strategy and an awareness of the Experts regularly analyze system 1 for dissonance between
logistic issues to achieve that strategy. Some things that their intuitive conclusions and the patient in front of
help are equipment checks, live practice, mental rehearsal, them—and this is done in real time. When perceiving
and in situ simulation (not too different from the X-Men’s inconsistencies, experts must switch to the slower, more
Danger Room). effortful type 2 thinking. In critical moments, expert
resuscitationists ultimately trust their intuition (system 1),
FILTERING DATA AND SYNTHESIZING THE but not blindly.
SITUATION
The physical position of the team leader in the room is ANTICIPATE AND ACT
also key to managing the rapid influx of stimuli.2 In the Despite vast experience and mental rehearsal, the expert
ideal location, the expert is central to all incoming data, but resuscitationist has to manage uncertainty and anticipate

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Lai et al EM:RAP Commentary

the unexpected.9-11,13,15,16 One helpful trick is a “defensive Emergency Medicine, New York University, New York, NY (Jain); the
pessimism” mind-set when approaching resuscitations. Department of Emergency Medicine, University of California, San
Francisco–Fresno, Fresno, CA (Mason); and the Division of
Despite the best planning, resuscitations can take
Emergency Medicine, Greater Los Angeles VA Healthcare System,
unexpected twists. Discussing these possibilities ahead of Los Angeles, CA (Grock).
time can decrease the stress and uncertainty. Through
effective communication, troubleshooting as a group, and
using the group’s shared cognition, this mental workload REFERENCES
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Author affiliations: From the Department of Emergency Medicine, paediatric emergency department. Scand J Trauma Resusc Emerg
UCLA–Olive View Medical Center, Sylmar, CA (Lai); the Department Med. 2016;24:1-7.
of Emergency Medicine, University of California, Los Angeles, Los 18. Marshall SD. Use of cognitive aids during emergencies in anesthesia:
Angeles, CA (Lai, Grock); the Ronald O. Perelman Department of a systematic review. Anesth Analg. 2013;117:1162-1171.

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