Navigating the Unknown: Managing Uncertainty in Military Medicine

 In this episode of the GSAC EP podcast, Dr. Amy Hildreth, Assistant Professor of Military and Emergency Medicine, shares her insights and personal experiences on navigating uncertainty in military medicine. From her first deployment to Kandahar to managing mass casualty events, Dr. Hildreth discusses the critical importance of developing uncertainty tolerance, managing stress, and using practical frameworks to enhance performance in high-stakes environments. The episode explores strategies such as preparation, cognitive flexibility, mentorship, simulation training, and mindfulness to help medical professionals and trainees thrive amid the unknown. Listeners will gain valuable tools for embracing uncertainty and leading with confidence on and off the battlefield.

#MilitaryMedicine #EmergencyMedicine #UncertaintyTolerance #StressManagement #Mentorship #SimulationTraining #MedicalEducation #MedicalPodcast #VeteransCare #ProlongedCasualtyCare

Transcript

Amy Hildreth: 0:00

Announcer,

Narrator: 0:07

welcome to the government services Chapter of the American College of Emergency Physicians. Podcast gsapp represents emergency physicians who work in the federal government, including active duty military National Guard and military reserves, as well as the Veterans Administration, Indian Health Service and other federal agencies, our mission is advancing emergency care for America's heroes. In this podcast, we bring you lectures and conversations with leaders in federal emergency medicine to help you better care for your patients and lead your departments. The views expressed on this podcast are personal views and do not represent the views of the Department of Defense, any branch of the military or the federal government, and they do not constitute endorsement of any product by any of these entities. The

Matthew Turner: 1:17

Hi, good morning. This is Captain Matthew Turner with another GSA sit podcast. In this episode, we have Dr Amy Hildreth, Assistant Professor of military and emergency medicine at USUS, here to discuss managing uncertainty in military medicine.

Amy Hildreth: 1:33

Hi everyone. Good afternoon. I am Amy Hildreth. I am an ER doctor. I work with Colonel Shen at USU. I wanted to talk to you guys today about uncertainty and uncertainty tolerance, because as I am new staff at USU, I'm trying to figure out what useful things that we can teach to help our students manage the wars of the future. We've had a lot of talks today about how we think things are going to happen, what we think we need to be prepared for. But the truth is, we really don't know, as with everyone, I don't have any fun disclaimers or financial things to disclose. So hopefully, over the next 14 minutes, we can talk about uncertainty and uncertainty tolerance, talk about how specifically this applies in the military setting, and review strategies to reduce uncertainty and build that tolerance. When I deployed for the first time. So I went to civilian medical school, civilian residency. I had been at San Diego for about nine months, and got sent to Kandahar, to the role three there with no experience. My first trauma was about 36 hours after we arrived and took over the hospital. We had a mass cow with 12 patients. I had a elderly. It was an elderly, an elderly service member, an older service member who was shot in the neck, spitting out blood from his mouth, gray and ashen, sitting up, clutching his neck, staring at me. I, from a medical standpoint, wasn't sure exactly how to manage that all by myself, without the Trauma Center at my back. How was? How was? What was the best way to approach that intubation and to handle that medically. From a security standpoint, my corpsman is telling me that they actually didn't set up the intake appropriately, and none of the patients were appropriately searched prior to bringing them into the trauma bay. So we were trying to also search and manage any security threats from all of these patients who had just come into the role three without being appropriately managed. We went river city for the first time, which I didn't know what that meant, that they shut off all communication and Internet, and I couldn't communicate with my family and tell my son that I was okay, and I had no idea how we were going to evac the patient. What was going to happen next? How long I had to take care of this incredible injury, as well as the 17 other patients that were there with me? Obviously, it wasn't all by myself, and we got through it, but that uncertainty on all of those levels was really just compounding and overwhelming. And I think there's so many of you in this room that have had to manage similar situations, and I just think that had I had been more prepared for that, I maybe could have done a better job, and I hope that I can help send more people forward. Being more prepared for what might happen. Dr natat showed this slide. So this graph earlier, I'm sure we've all seen it. That there's a certain level of stress that increases performance, but once you get pushed too far, you stop being able to perform maximally. This leads to anxiety, indecision, errors, you just are not able to function at your best. The more you can decrease your stress, reduce your uncertainty, and know that you're able to manage the situation, the more that you're going to be able to push yourself back into that peak performance in we just went over this with my scenario. But in uncertainty comes in all these different forms in military medicine, whether it's the medical care itself, the diagnosis, the treatment, whether it's the security and are you safe? Is your team safe? Or whether it's the ability to manage your own performance in future wars and lisco scenarios, we assume that we're going to have to manage with prolonged casualty care, from what we've learned in Ukraine and ongoing wars and ongoing conflicts where we don't have air superiority, we need to be able to manage this, and we can't eliminate the uncertainty, but we need to develop a tolerance for it. The goal is to be able to be confident in knowing what to do next, knowing whether to act or to wait, even if you're not confident in your knowledge and what's what you're aware of. Dr hello and her colleagues came up with this wonderful framework for reducing and managing uncertainty. So the idea is to reduce your uncertainty as much as possible by recognizing it, classifying it, and increasing your knowledge and then evaluating and figuring out how you can move forward with the decision frameworks that you have the biggest issue is the unknown unknowns, right? We can go and try to plan for what we know might happen, try to plan for what we think might happen, but it's those things that we don't even know we didn't know that always come back to really bite you. So how do you prepare for that? And how can you be aware? You have to be mindful of your assumptions and biases. You have to look for signs that you're missing things. You have to question your own judgment. You have to ask for help. All of these things can help, but again, you can never make it all go away. You can classify your uncertainty and put it in different buckets in order to help you try to be able to manage it better. Some of these things that we talked about diagnostic, resource evacuation, uncertainty, thinking about different perspectives. How can I think about this differently? How are other people thinking about this? I might have a lot of experience from my civilian trauma background. But what can I learn from my corpsman who was deployed before? What can I learn from the surgeon that I'm deployed with? What is the success look like for me? What is my co trying to accomplish? What is leadership trying to accomplish? What is the patient trying to accomplish? All these things might help create a better picture, acquiring as much knowledge as possible. Hopefully, this is happening before you get sent somewhere where you have to manage this, but you can still acquire knowledge in the situation. While you're there, the patient will tell you so many answers. If you ask in prolonged casualty care, one of the only things that we have that is really a benefit is that prolonged time with the casualty to continue to reassess, getting those vital signs, getting those updates, using your ultrasound, as Dr Apata showed us how to do, will help use all our available resources. There are decision making approaches that can help us as well, utilizing your heuristics and mental shortcuts, utilizing the shared decision making in your team that we talked about, and going through with scenario planning. Fuzzy Logic is using your kind of degrees of truth. There's inherent ambiguity, so you're using that flexibility, the more that we can harness our cognitive flexibility and be able to go. From the present at hand to managing the acute blood coming out of the neck wound, as well as the big picture of, how do I manage all of these patients in the department? How do I manage my team? How do I manage the long term goal, planning the better off that will be? So how can we build a toolkit to get better at managing uncertainty and to increase our uncertainty tolerance. One of the best ways to learn is to practice until we get all the mils partnerships set up and everyone can go to Penn with Dr de Forest. Sim is an excellent way to practice, especially in training, engaging in reflection can also be incredibly useful. Mindfulness techniques have been shown to help us manage stress in the moment. The more that you can stop, take a deep breath, do your own pulse, check and reduce your internal stress, the better you'll be able to manage these scenarios in the moment, and then thinking about that growth mindset and that cognitive flexibility. So just the idea that you can manage this, which we all learn throughout our emergency medicine training, that idea of what is the next and most necessary step that I need to take, just as when you're driving in the dark with your headlights and you can only see so far in front of your face, as long as you can keep making those next decisions, you can get to where you need to go. Another excellent pathway is seeking incredible mentorship. It's one of the amazing things about conferences like GSA Sup, where we all have time to get together and talk and learn and share. So again, I can tell my students my experiences of what I went through, but that's not going to be what their experiences on their deployments in five or 10 years are going to be. However, hopefully some of these frameworks and stories will help us, just like Dr Mabry was talking about, learning from our history can really help us better, be prepared for the future, going to our available resources, our excellent guidelines that we have, focusing on what we can control and recognizing our limits in crisis, it's really important to be okay with the acceptable and not always striving for the best possible outcome, because that will can short sight you and keep you from being able to manage everything appropriately. That is all I have. I believe I thought I had a thank you slide. I'll take any questions.

Unknown: 13:01

Thanks. Amy, kind of a comment on on building your uncertainty tolerance. I think another thing for those of us who work with medical students is having them realize, to be honest with your uncertainty tolerance, especially when you're mentoring people, whether or not to go into emergency medicine, and there are certainly people that should not be in the field that we're in, and just realistically can't be. And obviously, in most in this crowd, it's it's too late for us, but, but those medical students who are considering careers in emergency medicine instead of just trying to recruit people into our field that we all love, I think medical students need to be honest with themselves about their uncertainty and and stress tolerance,

Amy Hildreth: 13:40

although I would challenge you, Captain Butler, that we can grow our uncertainty tolerance, and there are ways to improve it and so but you should. We should all think critically about what our own uncertainty tolerance is and whether emergency medicine is right for us. But if you are in military medicine and you are not comfortable with uncertainty, you are probably in the wrong place.

Unknown: 14:07

Great point, but certainly just responds All right other questions from the audience.

Amy Hildreth: 14:14

Thank you so much. Thank you.

Narrator: 14:22

GSA, gsacep is proud to be the premier Continuing Medical Education Source for military and federal emergency physicians to purchase. CME for the episode you just listened to, please click on the link in the show notes the government services Chapter of the American College of Emergency Physicians promotes quality emergency care and enhances the development of Emergency Physicians who serve our nation from training through retirement. Learn more about our chapter at WWW dot GSAC ep.org, you.