On Combat, response
Have you read on combat? If not turn away right now, you need to at least listen to the EM-Crit Podcast on it (http://emcrit.org/podcasts/emcrit-book-club-on-combat-by-grossman/) as your intro. A number of points were covered here and its the perfect starting point.
During a pre Emcrit book club world Ian Miller of @Thenursepath tweeted back and forth regarding David Grossmans OnCombat in responses to a tweet by Cliff Reid about his (unknown to us) upcoming Podcast on EMCrit.
While obviously not negative Ian mentioned some of the more unfavorable outcomes of military style training and in particular asked why we would take training points from organisations with such a high PTSD rate.
Thanks to Ian for giving me the opportunity to talk about why On Combat meant to me.
Obviously healthcare workers aren’t the target Grossman was writing for, so large sections of the book can be discounted or read for interest only.
The target audience is combat soldiers, special forces and those preparing for combat or leadership roles in the military. However I put that one aspect of our jobs is similar we can go from routine to high performance in seconds, without warning.
Now obviously having read the book a few years ago while in the Army I took a lot of valuable lessons from the book that have changed the way I do business throughout that time and now that I’m out in the streets a number of lessons have stuck with me.
TRAIN HOW YOU FIGHT! A point bought up in the book is the transition from round “bullseye” targets to human shaped targets increased the number of soldiers that would fire at the enemy, this brings home the point about training how you fight. Whats the significance of this, that changing the way solders trained to more closely mirror the combat environment with engagement of humanish targets lead to greater success. The idea was to build a reflexive response instead of a cognitive one. Why can’t we learn from this, or do we do it daily, think about how you set up for cannulas everything in the same place? Knowing when you put your hand down the item you want will be there, reliance on muscle memory when your eyes are busy. We plan our resus bays so everything is in the same place, the MET team uses their own equipment ensuring they have their requirements taken care of and know where everything is to maintain control of their environment and team. For the most part in some places we are already doing this. The introduction of talking, vomiting, fitting manikins into sim ensures we don’t have to do the awkward pause, look at the educator await a response. Because guess what, do it in practice you’ll do it under the pump. At my first cardiac arrest as a student I walked into the room doing the cursory head bob/traverse for “Scene Safe” with my blue hands in the air and pointing to my eye ware (want a way to make Paramedics think your weird as a student, do that).
Mentioned in the pod cast is the officers that would catch brass in their pockets leading to them being killed with and empty weapon and a pocket full of brass. The fought how they trained.
Under stress you do the same thing you always did in training, why? Its familiar its comfortable its safe to you, its tough to think when your mind is racing and your pulse pounding its what you’ll fall back to.
The book talks on time dilation and compression, reminding people that in times of extreme stress, that tunnel vision, auditory exclusion and memory loss (among other things can occur) but we all know this. I’ve been victim to this my self a few times. In the military we used to train to look over and around out weapon systems during and after a contact, because of this tunnel vision, training to look around was an stratigy to maintain situational awareness. Which I still do to this day, I look away from my patient, I look at my team I look at bystanders and back onto my patient, orienting me to my surrounds, ensuring no-one has entered the room that I didn’t know about and ensuring my partner is on track with what they are doing (and I’m sure they do the same to me). This process of ensuring to monitor my surroundings obviously didn’t come from the book, but its mentioned.
The book also talks about Stress Inoculation training. Having undergone training involving fatigue and stress inoculation I think I came out all the better, this was mirrored in my ambulance class the military individuals felt more in control, had a greater perception of the teams actions and were able to effectively lead the small team better. Obviously we didn’t get this all from reading a book, the benefit was gained from going through the training. Small stress inoculation sessions in my opinion have a place in training of Emergency Service personnel and emergency hospital staff. Notice how the experienced staff let nothing bother them, the old hands are calm and collected in a crisis, because they’ve been through this before. The old hands have in essence stress inoculated themselves through past experience and previous stressful situations. Surely there’s benefit to be gained from performing this in a controlled environment for junior staff and providing them with relevant teachings and feedback. Recording and re-watching the sessions would also show them how their memory and the actual timeline and events match up( I was amazed the first time I did this how they didn’t match up in a huge way).
This book isn’t going to competently revolutionize the way you practice your particular branch of medicine. What it will serve as is a primer for you to think about the things you do. Think about trialing some combat breathing and trying to undo some of your bad habits that will cause you to come unstuck in an emergency or high stress situation.
Most of the benefit I’ve gained from this book wasn’t in the book, it was in seeing the lessons learned from the book applied to real world training. This book will not make you a better Doctor/Nurse/Paramedic/Firstresponder what it will do is stimulate thoughts on how you do things, how you can do them better and how you and your coworkers can train better, simulate better and prepare yourselves for the rare, unexpected and uncommon situations.
The idea of this post isn’t to get you to join the Army to improve your situational awareness. Its to get you to think about reading a book, which may give you pause to think about how you do things and maybe change a few of your practices so they work better in the heat of the moment. Maybe if your a NUM, Manager, Consultant, ICP, Educator (Doctor,Nurse, Paramedic) you can use this to think about how you train people and what your delivering in terms of training them for the uncommon stressful situations.
What I loved about this book was the science and explanation it put behind routine things. In training the explanation as to why we did these things was often just “because we do, now just do it”. The book puts all of that in perspective and being more mindful of why each of the minor things we did was important lead to a greater compliance on my part with the basics. By bringing it out of the realm of “because that is the way we’ve always done it” and into the “this is why” made for a greater adherence on my part. My Army coworkers reported a similar effect if they had read the book
I’m often thinking about how fortunate I am to have had situational awareness and mindfulness under stress drilled into me over the course of my training, I think its makes me better as a Paramedic, where environmental control and awareness in a stressful situation can be the difference between losing control of the team or environment and yourself as an individual.
Thanks again to Ian for providing the kindling for this post. As I’m sure you know I’m a huge fan of your work on Social Media.
Mitchell has served 4 years in the Army Reserve as an Infantry Soldier and a Medic, Now working for an Ambulance Service having completed his degree in Clinical Practice (Paramedicine) through Charles Stuart University. Mitchell Enjoys Headlamps and Human factors, reading books on various topics, bush walking and thinking about various things both related and unrelated to Prehospital Care.
ON COMBAT: The psychology and physiology of deadly conflict in war and peace
EM-Crit Podcast 118 and associated show notes. http//emcrit.org