Cognitive Offloading

[VentMonkey]

To the trainers and preceptors out there, does anyone actively enforce this principle? If so, how do you go about teaching it?

It's definitely not a new concept, but I've found more often than not, most newer students, trainees, or employees don't quite seem to grasp how it works, or the importance of the concept. Subsequently I'll see the same people needlessly struggle through a "high stress" call had they adequately prepared.

The podcast that I've attached is a tad outdated. And it makes mention to checklists and the like, which are great, but specifically I'm referring to the pre-shift checkout of items so that you know exactly where things are when needed.

It's a big reason that I don't miss being an everyday trainer; it's very hard to constantly watch someone needless drown had they simply taken in the advice learned from those before them. Essentially, "failing to prepare is preparing to fail". Thoughts?

Episode 13- Cognitive Offloading - Medschoolmedic

Sometimes thinking is hard. The answer to all of these is known as cognitive offloading.

medschoolmedic.com

 

[NomadicMedic]

I do a lot of this, especially with new paramedics.

One really effective way is to video them working through a difficult scenario and then show them the moment where they became task-saturated. You can also use data to illustrate this point well. The Zoll online code data works really well. I love the expression "Time is elastic" to describe how paramedics become task-saturated and overloaded when working on a difficult problem. For example, video and time how long it takes for a medic to calculate a drug dosage while in the midst of a megacode.

I like to teach the concept of offloading intensive tasks like airway and IV access to an iGel and IO to allow for focus on more mission-critical aspects of care. Showing them the individual steps in each can sometimes illustrate how quickly they get in the weeds on simple tasks.

 

[StCEMT]

One area that I know really stresses people I like to teach is just knowing how to troubleshoot. HEAVEN and SALAD go hand in hand with this. If you're mentally prepared for the possibility, rule it in/out, and have a foundation of muscle memory in place to address it then you are far less likely to freeze. Instead, you find a problem, mentally shift gears, and address it.

But I try to show people to big picture too. To address a problem requires and understanding of it and the solution (ie HEAVEN --> SALAD). Taking the stress level down a few notches by understanding the problem, process, and the way they go together helps significantly. I don't stress about messy airways because I know how to fix them. I don't stress about anatomically challenging airways (barring the extremes), because I know what is in my toolbox and when to use what tool so I can be successful...as well as having used many of said tools in real situations.

There's something to be said about the making mountains out of mole hills. Not that every stressful encounter is JUST a molehill.... but demystify it a bit and take some fear out of the equation and replace it with knowledge so they can actually focus on the process and not see an impossibly large problem. Mindset goes a long way to our success. You can either be driven by fear or a healthy level of comfort and confidence....one of those will make the process smooth and a smooth call hits transition points oh so well.

 

[Tigger]

The pre-shift checkout is essential and I try very hard to show new medics/students how it can be important. Knowing where every last item is essential, you just can't afford to bother with devoting thought to locating something when things aren't going great. I also take this further with our medications. I think you can really help yourself by knowing the concentrations of the medications carried, or at least the commonly used ones and anything used on a serious call. Realistically, these do not change that often and if they do you should know the minute you check your truck out. It's great to be able to calculate expected drug doses on the way to a call down to the ml so that work is already done. Even if you don't feel the need to do that, it's nice to feel confident that your math is right since you already did it in a low stress environment. Most adult doses are fairly consistent, but I reallllly don't want to be calculating pedi doses on scene if I can avoid it.

I also encourage preceptees to verbalize their plan A, B, C etc. As an example, "we are going to give this patient X medication, you are going to get an IV started, if you don't get it I want you to start an IO and tell me when that's done. That way when they are task saturated, anyone with us can speak up and say, "hey, we missed that IV, it's time to go to the IO." Even the students that are super dialed can benefit from this since eventually they'll have a call that doesn't go super well.

True mastery equipment matters too. I need new folks to know the monitor inside and out. If the monitor isn't getting you the values you need, figure out why and fix it. But you can't do if you don't even know how to change leads. Same with IV pumps, vents, CPAP, etc. It's so easy to become laser focused on the device and suddenly the call slips away.

I also find that we have great cardiology education in this area, which can be challenging early on. Students are great at finding every last abnormality, but their process takes a long time. I try to work them to keep that knowledge but also know how to systematically work through an EKG quickly to determine if there is a cardiac issue that needs fixing now to manage a sick patient. This also helps when they get a visually intimidating EKG to fall back on a process that will get them to a point where they can start the initial steps to managing the patient and then come back around for a detailed interpretation.