GSACEP Lecture Series: Head in the Clouds: The Importance of Mindset Downrange, in the Hospital, and in Everyday Life

Dr. Meaghan Keville is an Active Duty EM physician stationed at CSTARS Baltimore at the R. Adams Cowley Shock Trauma Center. Graduated USU in 2010 and then completed EM Residency at Wright Patterson AFB/Wright State University 2010-2013. She has been forward deployed with CCATT, TCCET and with a field surgical team in support of USSOCOM.

In this lecture, she discusses the importance of mindset and mental fitness in medicine and as she has recovered from injury.

For access to the slides and to view the whole lecture, visit:
https://pheedloop.com/GSS21/virtual/?page=sessions&section=SES77CTYP9E0I4MOC

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Transcript

Meaghan Keville: 1:02

Hello again, everyone and good morning. For those of you that I may have missed yesterday, I'm making Cavill, an active duty Air Force em physician at sea stars in Baltimore. Here to share with you today a bit more of a personal topic, a look into wellness and cognitive performance.

Unknown: 1:56

On February 20 2020, my team was on alert at a small FOB when a 107 rocket round impacted about 30 meters from my aircraft, and a small fragment from that round came through the wall where I was seated. All I remember from that moment is feeling like someone had hit me in the back with a baseball bat full swing. This small fragment struck the body armor that I was thankfully wearing. I didn't know it at the time. But that event would change a lot of things for me. I woke up the next morning in a fog with a pounding headache. My head had been leaned against the skin of the aircraft when the blast had occurred. And I was feeling the effects of the TBI later that morning, and not came on the team tent door, and a well respected Senior Chief from the Special Operations team that we've been supporting, asked to speak to me. He'd heard about the incident the day prior and had come to see if I was doing okay. I told him I had a bit of a headache, but I would be fine. He looked at me sort of doubting Lee and said, I know you're physically okay. But are you really okay? I told him that things would heal. And I knew I was lucky. Things could have been far worse. If I hadn't been wearing my body armor. Since we were inside the house goes on FOB. Or if the frag had been just slightly higher above my plates. This guy knew better and asked me if I'd go for a walk with him. He told me he'd been here before in the world of near misses. He told me about how he thought he was fine too. Until about four months later, when he found himself drinking heavily daily, constantly angry at odds with his wife and yelling at his kids. He told me how he finally realized how the Near Miss had affected him. And he'd found some help. I was humbled to hear that someone I considered far braver and tougher than I would ever be had struggled. But I'm grateful that he told me when I arrived back to the US a few weeks later, I was still having headaches and struggling with a bit of a post concussive syndrome. I followed up with my primary care doctor and began treatment at the National Intrepid Center of Excellence. And then COVID arrived, I found myself working q3 Call in the ICU watching young, otherwise healthy people die on ECMO. Once again, working in a job that was high risk. Everyone was tired, and I was no different. Except that I'd never really adjusted to the time change of being back home, nor the sympathetic overdrive that would keep me awake after I'd come home from a call, not really allowing me to sleep when there was finally time for it. I was still struggling with post concussive syndrome, persistent headaches, short term memory loss, and I was downright exhausted. isolated by the virus from the people I cared about, and that I knew cared about me. I found myself one night, curled up alone and sobbing on my bathroom floor. It was in that moment that I knew what that operator had been telling me. I knew that if I didn't do something different things were going to continue to get worse. And I didn't know what that might look like. It was terrifying. I spoke with my leadership, and for the first time that I can really recall, I asked for an accommodation and for some help. I removed myself from clinical duties for a couple of weeks, and I began a very long road to recovery with a fair amount of health I began to learn about how our brains work, and began to investigate how to improve the performance of my own. Along the way, I found myself learning a few things that I wished I'd known before I'd ever been injured. So I'd like to share a few of those things with you. You might tell yourself, you haven't experienced any specific trauma, and you're pretty well adjusted. Why does any of this matter to you? This image is an important reminder that over 45% of physicians and 43% of em physicians reported having symptoms of burnout in 2020. And the evidence has linked one point changes in burnout scores with meaningful differences in adverse outcomes. Although the things we'll talk about today won't change your crappy EMR, difficult leadership or challenging patients, hopefully they will help you to deal with all of those things in just a little bit of a better way. Many of you may be familiar with Lieutenant Colonel Dave Grossman's interpretation from the book on combat of our physiologic response and ability to perform a task when under stress. As stress on the human psyche increases, there is a point of optimal functioning for any given situation. However, too much stress results in poor performance, it is an excellent model of how the mind and body will behave at a single point in time. However, I argue that this model is incomplete, as it only looks at the problem in the two dimensions one point in one time, and is unfortunately not how we live life. In order to give some depth to the mental model and incorporate the third dimension, time, I figured I'd start with one I assume as emergency physicians you're all familiar with. Not sure how the rate of D saturation has anything to do with stress and wellness. Allow me to explain. You'll have to pardon my drawings. But stick with me for a moment and hopefully it will make sense. Consider your personal wellness as the green line here. Whether you want to believe it or not. Each of us is human and has a point where performance and wellness can't stand up to stress any further and it begins to deteriorate. Much like Colonel Grossman referred to getting into the black. However, one must consider how long it takes to get to that point in any given situation, and how steep the drop will be once things begin to compensate. For example, here you are plotting along on your green line, a rather high performance individual. When you get some short notice orders to deploy, you travel across nine time zones, lose the daily support of having your family by your side, and begin to worry about your kiddo who's had trouble in school that sits in the back of your brain all the time, you're still likely to be able to perform at your normal capacity. But some of your available cognitive bandwidth has already been utilized. And your views may be just a little bit shorter. What is this cognitive bandwidth thing you might say? It refers to our cognitive capacity, our ability to pay attention, make good decisions, stick with our plans and resist temptations. Think of it like the internet bandwidth that may run through a cable like this one. There's a fixed amount of information that can be transmitted in any given time. Keep too many things running in the background and you can overwhelm the system. More on that later. But let's go back to you on your deployment. You're now midpoint through your six month deployment. You never quite adjusted to the time change and operations have been busy. It's been over 100 degrees every day. And let's face it, your fuse is just a little bit shorter. In addition to pay really has not started off well. There were three rounds of IDF overnight, the Wi Fi is down. The shower is cold and someone peed in your Cheerios. Turns out the likelihood that you will move more quickly from Colonel Grossman's condition red to condition Black is pretty darn high. And the chances that this could affect your performance on this afternoon's mission, also pretty high. The question then becomes how do we move the curve to the right and dare I say, flatten the curve? And is there a way to climb back up once we've started to slide off the edge? Can we buy back cognitive bandwidth? Well, logic would say there must be or we probably wouldn't be here talking about it. But it turns out like climbing any height it takes some work. I will preface by saying that in this talk Today, we'll probably only have time to scratch the surface on the continually growing amount of available information on cognitive performance and personal wellness, which in truth go hand in hand. And additionally, I am not a formal expert on either merely a person who learned some valuable lessons the hard way, and thought there might be someone in the room who could benefit from those things I learned. So let's begin. First is probably important to have a baseline understanding on the inputs that affect overall peak performance. Remember that cognitive bandwidth I mentioned? Well, here's your fiber optic cable. All of these factors play a role in allowing us to perform at our best, and we can influence them all in different ways. As we move forward, we'll look at some of the things we can do to influence the amount of cognitive bandwidth we have at baseline, and how to try to buy some back when it's limited. Let's start by looking at moving the curve to the right. We're increasing our baseline cognitive bandwidth. How do we build our ability to cope with long duration stress, often referred to as resilience. We used to think that it was done by repeated exposure to long sleep deprived periods with intense stressors and embracing the suck. It turns out what that builds is people who are broken and burned out. Now don't get me wrong here. This is not me saying that we shouldn't flex our bravery muscles, do hard things, take risk, fail and grow. This is me saying we've got to be smart about the way we do it. In order to create lasting improvement. We've got to utilize Ernie ability to rewire the brain to adapt in a positive way, neuroplasticity. But buyers beware. This is slow change managed by hormones such as cortisol, building neuro pathways, and it takes effort and time. In order to make a change, though, the first step is to recognize that our brains can be trained. Attitude is everything. This concept is adapted from the book Mindset by Carol Dweck. In it she explores the idea that adapting a growth mindset, a mindset that understands the abilities and success can grow with hard work. She introduces the concept of not yet the idea that success is not necessarily in having the right now right answer and not in perfection. But in the idea that if you don't have the right answer yet, you can reach it. And that success comes from the journey. That difficulty and effort don't mean that a person is not capable or not smart enough, just that they haven't reached the endpoint yet. Take a moment to ask yourself, Are there areas of your life where you've accepted that something just is as it is, and that you'll never never be able to do it? When is the last time that you challenge yourself to do something hard? Something that you could possibly fail. This brings me to my first recommendation. The idea of a mindfulness practice may sound a little hippie. However, evidence is mounting that mindfulness practices can help you perform better, be more confident, improve your mood and reduce anxiety. mindfulness practice allows a person to be more aware of where their cognitive bandwidth is focused at the present moment, to engage with the task at hand and to be able to recognize the things that may be pulling us away and shifting attention. Taking the time to allow the mind to wander gives it space to struggle with things that are important, but not necessarily active. It creates a window for the exploration of the past formation of memories, connecting learning experiences and dealing with residue. More on that in a moment. In addition, in the medical world, mindfulness practice has been shown to be successful in improving pain management, treating depression, anxiety, and improving coping mechanisms for patients with chronic disease. Understanding your own mind will help you to learn how to use it to perform to its maximum potential. There are many options to start a mindfulness practice, if you're willing to give it a try. There's little harm and it can take less than five minutes of your day. Here are a few great apps that can help. Many are free, including the PTSD Coach and CBT eye which have been developed and produced by the VA and have specific tools designed for people dealing with PTSD. You know that case? The one you will never forget the child that died. The baby you delivered the mistake you made. The woman whose husband shot her in the head, or the soldier whose life you saved That is residue. The pieces of intense experiences that we carry with us, we'll all demand to be recognized at some point. If processed well residue can create meaningful stories and memories to carry forward, share and learn, if not dealt with, these things can become a nightmare that plays on repeat, slows cognitive, bandwidth and needs of the soul. Consider a journal where you can process at the speed of handwriting, a standing meeting for coffee with a friend who has similar shared experiences, or scheduled time at the end of the workday. Five minutes before you get out of the car when you get home, to spend with the intense moments of the day. As mammalian primates we are designed to have increased levels of oxytocin when we are supported and have connection with our tribe. As it turns out, oxytocin does a bit more than stimulate lactation in mamas, all mammals demonstrate oxytocin receptor expression in the mesolimbic social decision making centers of the brain or the social survival region of the brain. These regions ultimately mediate aggressive, emotional and sexual behaviors, and attribute social salience to specific sensory or environmental stimuli. Additionally, animal and human research has also demonstrated a role for oxytocin in improving wound healing following traumatic skin injury. Most Recent studies have shown that stress induced increases and oxytocin levels may act as a feedback regulator to enhance recovery from stress related symptoms. And that social connections that increase oxytocin levels can promote both cognitive and physiological resilience. If you don't like any of those points, and you need one more good excuse to work on your connections with family and your tribe. Know that administration of oxytocin in rodents and primates leads to sustained weight loss by reducing food intake, increasing energy consumption and promoting promoting lipolysis. Yep, that's right. Improving your connection can help you lose weight as well. Gratitude is one of the concepts most commonly associated with well being from an empirical point of view. Despite this, we seldom use this concept, possibly due to a lack of dissemination of its scientific basis and clinical applications. At an anatomical level, the expression of gratitude is related consistently with a medial prefrontal cortex, and then a molecular level again, with none other than oxytocin. Gratitude has been associated with better physical health parameters such as decrease in pro inflammatory markers, better cardiovascular function with decreased blood pressure and improved heart rate variability. It also is associated with better sleep quality. From a mental health perspective, it has been associated with results such as higher levels of positive emotions and life satisfaction. Gratitude has been demonstrated to decrease anxiety and depressive symptoms, substance abuse and suicidality. In addition, it has been associated with better quality of life, and greater adherence to treatment and patients with chronic disease. Not sure where to start, consider taking a moment each night before going to bed. Try to think of three things you're grateful for. Challenge yourself to find the smallest things possible. Pro move, write them down. Many of us are well aware of the physical and sleep related benefits of exercise, but often forgotten are the cognitive benefits. Multiple studies have demonstrated that exercise has beneficial effects on cognitive performance, executive function, working memory, self esteem, mood and motivation. So if you're ready to take over the world, you can get started with a few push ups. It wasn't until a few years ago that I recognize the importance of the third thing. The third thing is the thing that separates work life and home life. The icing in the middle of the Oreo cookie, you know, that is the best part. Research has shown that military members transition out of their active duty career. The people who tend to handle the transition best are those that have some sort of identity and meaning that isn't linked to the military. It reminds me of an anecdote a friend of mine shared with me. He'd gone on vacation to New Zealand and found himself chatting with a stranger at a bar. He asked the stranger what he did. The man replied, I'm a surfer. Now this man did not look like a professional surfer by any stretch. And apparently this was written all over my friend's face as the gentleman looked at him and replied, all of you Americans have got it wrong. Yes, I have a day job that pays the bills. But it's not what I consider as the thing I do, or who I am. How you define yourself matters. If all you are is your title, you will have a challenge when you no longer have that title. You may be thinking, Oh, this sounds great, but it also sounds like a lot. How do you really have time for all of these things? Creating a battle rhythm is something that the military is sometimes excessively good at. But as individuals, not all of us are, and yes, I get it as em physicians, we rarely have the luxury. But if we once again reach back to our primal roots as man mammals, we can learn that we truly are creatures of habit. Our circadian rhythms appreciate some predictability, allows our body to know predict and manage the timing of hormone release, and how and when to manage and conserve energy. In addition, having a battle rhythm frees up cognitive bandwidth, you might ask how? Well we each have a finite amount of mental energy that we can expend on decision making before our brain starts to look for a shortcut. It at least partially explains why weekend shoppers impulse buy and elite athletes make unaccountable decisions at the end of a game. decision fatigue is also a well recognized reason behind poor clinical decision making, decision avoidance and as a precursor to burnout. So if you're able to be efficient about the number of decisions you need to make in a day, if the questions about when to wake up when to workout I went to meditate are already answered, then there is more energy available for your brain to work on the more important questions like whether or not to give another unit of blood. There is very little objective data on this concept for deployment. However, anecdotal information indicates that developing a consistent battle rhythm downrange as soon as possible, helps transition occur more quickly and improves both physical and mental performance. We've now touched on a few ways to move the curve to the right. Let's take a few minutes to talk about some tools to help you climb out when you're running out of bandwidth. The stress response to the body was designed to protect us from predators and danger. But sometimes it can be less than helpful. The amygdala is the part of the brain that signals danger to the sympathetic nervous system. When the stressor is great enough, it can override the compensatory rational brain that keeps it in check. This is considered to be an evolutionary response to the environment where there is no time for rational thinking. However, in most situations we are exposed to this is an inappropriate response to protect our well being when our physical well being really isn't truly in danger. The best way to buy back some cognitive bandwidth is to get the amygdala back in check. Here are some simple ways to save your day. The first thing I'd recommend is take five. If you can take a few minutes to step away from whatever is the triggering situation. Go for a walk, breathe some fresh air. The University of Maryland where I spend most of my time has even developed the T five program where staff members can come and grab a take five bag for themselves or a friend. They've got a small bottle of water and a healthy treat. As it turns out your basic training ti had something right by forcing you to drink water all the time. Besides not becoming a heat casualty hydration status has actually been linked in some studies to both cognitive performance and mood. Who would have thought that those guys could have been doing anything that might improve your mood? Speaking of improving your mood, did you know that the neurotransmitter dopamine is most commonly associated with reward and happiness? Finding the things that trigger dopamine release will help to dial down the sympathetic nervous system and help to improve feelings of calm and focus to things integral to performance and high risk situations like the recess Bay. What's the best way to find some dopamine? Well, what do you do for fun? A surprisingly small amount of adults actually have an answer to this question. And the number is even smaller within a military culture that places a strong value on pulling up your bootstraps and giving 100% of yourself to whatever your country needs. However, play laughter and joy are an integral piece to managing stress is reported that in ancient Sparta, the second most valued skill in a man after his martial prowess was his singing ability. Think back for a moment when you were a child, or think about what you tell your children. When things are stressful. What does a good parent do? Well, they kick their kid out the back door and tell them to go play of course. So why don't we do the same? If play isn't your thing, tell a joke. If you think about it for a moment, you can remember being in a tough situation that seems to be falling apart. When someone cracks the perfectly timed joke. You'd better believe it. That's dopamine to the feeling of warm sunshine on your face. Dopamine, listening to good music, dancing, dopamine, is it starting to sink in yet? The last tool that I have for you is an old one, an easy one, an oft forgotten one. Ask any sniper and they will tell you that the best way to dial back the sympathetic nervous system and activate the parasympathetic is to breathe. Emotions have been documented to change breathing patterns, and breathing patterns have been documented to change emotions. Controlled patterns of breathing, thus can serve as a powerful tool to impact and shift emotional states. There are many ways to utilize this tool. And the best part is, no one in the room has to know you're doing it. As far as how to do it. There are a lot of different methods. The one most commonly referred to in the military populations is called the box method that can be seen here. Another method that is even simpler and focuses on the long exhale, which is more often associated with parasympathetic activity is to take two short inhales through your nose, and then a long exhale. Give it a try. I'll wait. I promise, no one's looking. As I come to a close, you'll have to forgive my blatant plagiarism of my current favorite podcast, the mission critical team Institute team cast, we're at the end, the narrator Coleman Ruiz talks about what to do on Monday. Here, we'll circle back to the first steps you can take to improve performance and wellness and the mission critical environments in which we all operate. I'll remind you that this is only a brief glance, and that there are many different ways to train your brain to perform at its peak. Number one, be vulnerable. have the difficult conversations. And remember that a person can drown in six inches of water just as easily as they can drown in six feet. That's why I'm here today. Because I know that I had the person who shared his struggles with me, not taking the time out of his day to check in and tell me about his experience. I may never have realized that it's okay not to be okay. And that asking for help is not a sign of weakness. So I encourage you to share your story. You never know what it might change for someone else. Number two, balance, self career family. All three require intentional focus and too much energy on any one of the three and the other two will suffer. Number three, do something for your brain and your body every day. This does not have to be complex for the brain. Take five minutes to meditate. Learn something new, that doesn't have to do with work. Write in your gratitude journal. For the body. Go for a walk, or a hike, ride a bike or play with the kids. Number four, have a third thing. Work workout and what? For me it's putting my head in the clouds. What will it be for you? And finally, don't forget to Bri if you're intrigued by today's discussion and want to look into these things further, here are some places I'd suggest starting. Thank you all for your time today. I'd be happy to answer any questions now or feel free to send me an email