Lessons Learned from a Decade of Conflict - Boekje Pienter

School shootings like the oneat Columbine High Schoolunderscore the need for EMSprofessionals to be aware ofhow the body’s response willundermine their best efforts inan active shooter situation.By Bruce K. SiddleAtrauma surgeon was recently involved in a case wherestress affected his ability to perform a tracheotomy. Thecase involved a tactical team officer, who was broughtto the ED with a gunshot wound that required an emergencytracheotomy. The surgeon knew the officer well, knew the membersof his tactical team and had actually trained with the teamon many occasions as their emergency team doctor. Therefore, aspecial bond existed between them.The officer’s wounds were serious, and his fellow officers refusedto leave his side. As the surgeon began what should have beena simple procedure, his vision became distorted and his handsbecame sweaty and shook, resulting in his inability to firmly graspthe surgical tool. A simple straight-line incision took severalattempts, leading to what he described as a “road map” of scars.In the end, the surgeon saved the officer’s life. The officer recoveredand is again active on the tactical team. But the surgeonconfessed to me that the stress associated with the seriousness ofthe injury, his personal association with the officer, and the peerpressure from the patient’s team members impacted his visualclarity, his ability to concentrate and his precision motor skills.Photo george Kochaniec / SygmaPrior to this event, the surgeon hadperformed dozens of the same procedures in avariety of conditions with absolute precision.So what went wrong?Operational CharacteristicsThere’s a saying, “To err is human.” I proposethat “error is subsequent to the human factor.”In EMS, human factors collide with the needto decide quickly and act precisely, underconditions that are dynamic, stress-inducingand occasionally hostile. The key to ensuringeffective performance under those conditionslies in understanding the body’s response tostress and danger.Consider for a moment the basic operationalparameters of the emergency medicalprofessional:• The mission of EMS professionals is toprovide care and save lives.• They operate in environments that aredynamic, unstable, time-sensitive and attimes hostile to their safety.• They work under the stress that is multidimensional—rangingfrom self-inducedstress, peer-based stress, patient stress andbystander stress—and magnified by theneed to treat/save the patient.• They are required to exhibit absolute precision—inperception, diagnosis, treatment(precise motor skills), communications(to fellow operators and the patient) andpatient protection.• They are constantly exposed to spontaneousand unexpected threats that can triggertheir startle response.Very few professions operate in extremeenvironments that also require precise skills;even fewer have the added stress of saving livesas their core mission. In fact, from the perspectiveof basic human physiology, the EMSprofessional’s mission is a scientific paradox: theoperational environment is extremely dynamicand often life-threatening to the operator; butthe operational requirement is extreme precision—theprecision required when threading aneedle, only there’s a life on the line.The focus of this article is the role of thesympathetic nervous system (SNS) as it relatesto the mission, operational environment andoperational requirements of the emergencymedical professional. My goal is to educateemergency personnel on the hard-wiredmechanics of the body’s stress physiologycircuitry and how it impacts precision skills,from complex medical procedures to suchbasic acts as opening medical kits and supplies.28 War on TraumaJournal of Emergency Medical Services