Ep 200 How EM Experts Think: Strategies for Pre-Shift, Arrival Ritual, Staying Focused, Managing Interruptions, Cognitive Load & Negative Emotions, Resuscitation Mindset, Post-Resuscitation Recovery

Which elements of your current pre-shift preparation contribute most to your mental clarity and performance, and what new practices might further optimize your readiness? With interruptions shown to increase task errors and decision fatigue, how can you strike a balance between being approachable to colleagues and safeguarding your focus for patient care? When confronted with a particularly challenging or emotionally charged case, what strategies have you found most effective for maintaining professionalism and clear decision-making under pressure? How often do you debrief after high-stakes scenarios, and what impact has debriefing—whether formal or informal—had on your team’s learning, emotional recovery, and future preparedness? What strategies do you use to foster open communication and ensure all team members feel empowered to provide input during high-stakes situations? How do you mentally and emotionally shift from managing a critical resuscitation to treating lower-acuity patients without compromising your focus or energy? When faced with a complex case where diagnostic clarity is elusive, how do you prioritize your next steps while maintaining confidence in your decision-making process? How can apps, personalized workflows, or EMR tools be better utilized to minimize cognitive load and enhance clinical decision-making during shifts? These are just some of the questions we pose in this 2-part podcast series on How the Experts Think with Dr. Reuben Strayer, Dr. Scott Weingart and Dr. Mike Betzner…

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Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Anton Helman December, 2024

Cite this podcast as: Helman, A. Weingart, S. Betzner, M. Strayer, R. Episode 200 How EM Experts Think: Pre-Shift Preparation and Arrival Ritual, Staying Focused on Shift, Managing Interruptions, Managing Cognitive Load, Handling Negative Emotions, Resuscitation Mindset and Execution, Post-Resuscitation Recovery. Emergency Medicine Cases. December, 2024. https://emergencymedicinecases.com/how-the-em-experts-think-part-1. Accessed January 22, 2025

Pre-Shift Preparation and Arrival Ritual

Effective preparation ensures you start your shift focused and ready. The chaos of the ED demands that clinicians arrive mentally and physically ready to handle high decision density, frequent interruptions, and unpredictable challenges. By developing pre-shift rituals, emergency providers can start shifts with clarity and confidence. Think of yourself as an elite athlete who requires both physical and mental training to maximize performance.

Key Tips:

• Mental and Physical Routines:
  • Ride a bike or run to work or perform a quick exercise routine to clear the mind
  • Take a cold shower to invigorate the body and mind
  • Consume protein-rich foods to sustain energy levels
  • Set up your workspace the same way each shift to reduce cognitive strain
  • Arrive early to establish a flow without interruptions
  • Establish a ritual to leave your personal issues at the door and mentally commit to the shift
• Mental Framing:
  • Listen to medical podcasts or inspirational music during your commute to set a positive and engaged mindset
  • Practice gratitude by reflecting on the privilege of being a physician
  • Use positive self-talk to reinforce your readiness and confidence
  • Visualize success and mentally rehearse procedures and challenging scenarios

Deeper dive on Shift Preparation on EM Cases with Rob Orman

Additional strategies: The EM Expert Mindset – A Female Perspective

Strategies for Staying Sharp on Shift: How EM Experts Think

Sustaining focus in the ED requires active management of interruptions, cognitive load, and thoughtful team communication.

Managing Interruptions

Interruptions are ubiquitous in the ED and can lead to task errors, slower task completion, and decision fatigue, ultimately leading to poor performance and poor patient outcomes.

1. Recognize interruptions as patient safety risks, not just an inconvenience. Frame interruptions as detrimental to care and prioritize focus over availability.
2. Strike a balance between being approachable to colleagues and safeguarding your focus for patient care.
3. Asynchronous Communication: Use Post-it notes or EMR messaging systems for non-urgent tasks.
4. ECG Handling: Implement a designated pile system to address ECGs during free moments.
5. Prioritize and Delegate:
   • Finish the current task before addressing interruptions
   • Delegate non-critical tasks to team members when appropriate
6. Focus on Critical Interruptions: Establish protocols for when interruptions are essential (e.g., for critical lab results or a deteriorating patient).

Strategies for Managing Cognitive Load: How EM Experts Think

One patient at a time, personalized knowledge management system, maximum safe capacity and planning for negatives

Cognitive overload in the ED stems from high decision density and attempts at multitasking demands.

• See one patient at a time and complete tasks sequentially to minimize task-switching errors and maintain focus
• Develop a structured approach to patient assessment and treatment, heuristics and personalized workflows for common cases by maintaining a personalized knowledge management system for quick reference during shifts. Consider creating your own algorithms for every patient presentation with corresponding documentation templates to reduce decision-making strain. Dr. Strayers Algorithms & Heuristics
• Know your maximum safe capacity and work at 85–90%  at all times to conserve mental energy for critical cases.
• Plan for negatives: Anticipate outcomes for diagnostic tests and decide on next steps for negative results during initial patient evaluation
• Speak with your group about the advantages of shorter shifts; 6-8 hour shifts minimize decision fatigue and may improve performance

Strategies for Effective Flow

1. Start Strong
   • Arrive early to your shift and address complex patients early in the shift to reduce bottlenecks and reduce backlog stress
   • Commit to decisions promptly and avoid overthinking
2. Commit to Dispositions
   • Decide on admission or discharge at the first patient encounter for most cases
   • Review your consult-to-admission ratio to identify opportunities for improvement
3. Real-Time Documentation
   • Chart immediately after seeing each patient to finalize encounters and prevent backlog
   • Use documentation as an opportunity to reflect on diagnostic and treatment plans

Strategies for Handling Negative Emotions on Shift

The emotional landscape of the ED is fraught with frustrations, conflicts, and high-stakes scenarios. Emotional resilience is critical to maintaining high performance.

First, gain insight into your emotional triggers which may include difficult or manipulative patients, negative interactions with consultants or other staff, crowding, long wait times and administrative inefficiencies, and recognize which ones are within your control to change, and which ones you can effectively act on to reduce stress.

Strategies to minimize impact of negative emotions on shift

• Basic physical needs: Stay hydrated, eat regularly, and take short breaks to reset. Step outside for quick exposure to natural light and fresh air.
• Reframe Situations:
  • Shift focus from frustration to empathy by considering patients’ perspectives
  • Use stoicism to accept uncontrollable factors, such as system limitations or consultant behavior
• Mindfulness: Recognize and acknowledge rising stress levels and use deep breathing to regain composure. Escort intrusive negative thoughts out of your mind by refocusing on the present.
• Reframing: Shift perspectives on difficult patients or consultants by considering external factors
• Positive Self-Talk: Replace negative thoughts with actionable implementation intentions, i.e, “When X happens, then I will Y.” e.g., “When I’m told there are no ICU beds for my sick patient, I will continue to provide excellent care for my patient in the ED”.

Resuscitation Mindset and Execution: How EM Experts Think

Preparation – Beat the Stress Fool Framework:

Breathe: Perform tactical or vagal breathing to reduce anxiety.

Talk: Use positive self-talk to boost confidence.

See: Mentally rehearse the steps of the resuscitation.

Focus: Use a relaxation cue word like “smooth” to anchor yourself.

During the resuscitation

• Control the Environment: Maintain a resuscitation-ready room
• Take aggressive steps early to stabilize physiology (e.g., vasopressors, airway control)
• Use an expanded ABCs “resuscitation heuristic” to methodically address patient deterioration
• Anticipatory Guidance: Speak aloud to guide the team and articulate your thought process. Speak your plan out loud to align team members and minimize errors. Invite feedback from the team by asking, “What are we missing?”
• Tactical Pause: Recap the case aloud to refocus and invite input from others

EMCrit Resuscitation Communication

Managing the dreaded mind freeze during a resuscitation

1. Default to ABCs: Focus on airway, breathing, and circulation to reorient priorities
2. Perform a Situational Recap/Tactical Pause: Summarize aloud what’s been done and invite input; this often helps clarify your next actions even before input from others is voiced
3. Call for Help: Involve another physician to bring a fresh perspective

Strategies for Post-Resuscitation Recovery

Transitioning back to the rest of the ED with a fresh mindset is essential after high-stress cases. Reset mentally and emotionally to continue providing high-quality care.

Strategies for Recovery:

1. Self-Care: Take a moment to rehydrate, grab a snack, and change into clean scrubs
2. Debrief:

• • Conduct brief team debrief to address teaching points and process emotions

1. • Consider 30 seconds of silence to honor the patient and the team’s effort
2. Transition back with self-therapeutic cases: Focus on being present with simpler cases to restore cognitive equilibrium. e.g., see a low-acuity patient, such as an ankle sprain
3. Acknowledge Success and Express Gratitude: Reinforce team morale with positive statements, e.g., “We just saved a life. Great work, everyone!”

Key take home points for How EM Experts Think

In Part 2 of How the Experts Think, we tackle strategies around complex non-resuscitation cases, cognitive debiasing, effective decision-making, and training practices outside the ED.

The EM Expert Mindset – A Female Perspective

Drs. Helman, Betzner, Strayer and Weingart have no conflicts of interest to declare