Hello everybody. Welcome back. Welcome back to the Sim Kit podcast, and our conversation today is gonna be a little different, which I’m excited about.

Oftentimes, if you’ve been listening for a while, we’ll have content that we think we’re experts in or. We are experts in talking on a material, or we have people that are coming from outside specialties or perspectives like our orthopedics one, uh, EMS, other people that have joined us to give their opinion, expertise.

Today again, we’re gonna do it a little bit differently. I do have a special guest in Dr. Elizabeth Calhoun, who is an emergency medicine position and the chair of the Women in Emergency Medicine section of a A EM organization that’s very near and dear to my heart, and she and I are gonna be talking together about preparedness, kind of preparedness for shifts.

Particularly when you are switching, I guess you’d say, when you’re practicing in a wide variety of settings. So Liz, thank you for being on the podcast and just tell the listeners a little bit about yourself. Well, thanks for having me, Jason. Um, I am a mid-career attending emergency physician. I work typically in non-academic or community settings.

I did my residency training in two separate places. Actually, I was part of the Hahnemann cohort when the hospital closed. That was Drexel’s emergency medicine program. So I did my first two years of training there and then finished my last year of residency training at Temple, also in Philadelphia. So between training at Hahnemann and Temple, I’m.

Practicing in pretty austere environments. While Philadelphia doesn’t technically have a county hospital, if we did have one, it would have been Temple and Hahnemann itself. The unofficial hospital model was do more with less. So even practicing in academic environments, I’m used to not having quite all of the resources that you might have at a better, better funded place.

After that I continued to work in a community settings, and I recently broaden in my horizons. I was a locums physician in rural and critical access hospitals in Northwestern Pennsylvania, and now I have recently joined a democratic group based out of the eastern shore of Maryland. Fantastic and so great to have a kindred spirit.

I am a temple grad, uh, so I understand the, we’re not technically county, but we might as well be great place to work, train, get a little ice in your veins, and then, um, carry on. And your, uh, after residency experiences are gonna be super helpful for this conversation as well. So, uh, as I mentioned, I want to talk about, I think what probably unique.

Topic in medical education or or emergency medicine podcasting sphere, which is shift preparedness. And we’ve talked, I’ve heard, and others have talked in some degrees about it, but shift preparedness and the ability. To adapt to environments. So I like to structure the talk, uh, with some of the science structures that are out there that one could consider, and then have a back and forth discussion about what seems practical and applicable.

Because sometimes, you know, science, particularly med ed, science doesn’t always meet that sniff test of applicability are actually being practical. How’s that sound for you, Liz? That sounds great. Um, when I have worked with residents, I think that’s one of the things I like to stress, is that we train in environments and we teach you things that do not reflect the environment that you may actually be practicing in.

Given that something like 80% of us go into a community setting after training. Yeah, true. Great point. And you know, I’m as a kind of community academic hybrid myself now, a lot of my artificial, increasing the end of patients for our residents, which I feel is a, a responsibility of ours is okay, how would you manage this patient if neurosurgery couldn’t come to the bedside, if their oncologist was not readily available via phone?

And so. Thinking about that, thinking about working, not just outside of tertiary ivory tower medicine, but then we start thinking about really extremes in critical access osteo environments. It’s gonna be interesting to think about that and how you might put your cap on differently as you prepare for those shifts.

So yeah, let’s talk first about that. You know, as a clinician, myself, I work in a, a good variety of environments actually really. Love the structure because it gives, you know, breaks up the mo you know, the spontaneity, the monotonous element of what we do. Uh, although every shift is intrinsically variable and you have no idea what’s coming through the door.

But I work in, from a freestanding emergency department, actually has a little behavioral health unit on the floor above it, but nothing gets admitted there. Um, all the way through a community. Setting that’s a, a busy community er, and then you know, that tertiary or quaternary center. So then in thinking about switching between these environments, we have to think about the context and our own adaptability, for lack of another term, because you can start to develop cognitive friction.

If you can’t switch your brain between these, so there’s a lot of potential differences in these, right? There’s the resource availability element, there’s consult culture, nurses and nurse flow. Particularly nurse expectations of what they’re going to be, do be doing, the order sets we use, all this stuff can come into the fore, and these differences could also actually extend further, especially if you’re going across state or things like that where they’re.

Medical, legal climates might be different. Certainly acuity of the patient and their course, the thresholds for transfer, the list can get pretty long in terms of the potential differences, it’s all emergency medicine, but there’s a far cry in some of the different environments that we practice in. And you know, we already have to manage a huge cognitive load just in providing patient care.

Right. And it’s actually rarely our own knowledge base. I feel like many, most of us are getting adequate training. Come out ready to provide care independently. So the care provision isn’t always an issue, but the switching and working across different systems and system-based frictions that can happen.

And what ends up happening is there’s kind of a mismatch in, I guess, expectations, whether those be our own expectations as providers. The patient’s expectations are nurses, as I mentioned briefly. You know, the list goes on. So before we talk about how to mitigate this mismatch, Liz, how does this framework, um, and discussion sound to you?

Does it ring true with your clinical practice in thinking about all the competing interests? This sounds grounded in my everyday reality. I mean, starting with setting patient expectations, especially in the days of boarding and increased volumes and decreased emergency departments. That’s, you know, one of the things that I usually do is set expectations for the patient, whether it be the amount of time it takes to get test results, back to the expectations of are we going to plan on admitting you versus is this gonna be a likely discharge home?

Appropriate referrals and I set them early so that there’s no surprises. And I found that it helps mitigate some stress, but it’s still there. And you know, even when you are out of training and you’ve secured that first job and you think like, I have a place where I can make new expectations and I can ground myself, you still might find yourself having to cognitively switch between different environments.

All within days of each other. My current job has hospitals spread over two states, and we have everything from a freestanding emergency department where the attendings work 24 hour shifts to a tertiary care referral center. But things still need to be referred out to two different community settings in very different environments in terms of patient population and therefore patient expectations.

And I think the last thing that you said rings true about nursing staff as well and kind of expectations there. And that admittedly is one of the things that I’ve noticed I struggle a lot with, um, especially since COVID and when we had the exodus of the loss of nursing staff. You know, early in my career, I can remember when charge nurses in the emergency department had to have 10 years of experience.

You had to have five years of experience in the ED just to be a triage nurse. And forget about starting out in the ED as a nurse, you needed so many years of med surg or a different environment just to get on the waiting list to get in. And now we’re seeing brand new grads in the ed. And that means that I have to manage my expectations for what their capabilities of are differently.

It’s just a matter of no longer seeing nursing who has the same or experience anymore, and that has to shift the way that I work my practice with them. Yeah, I, I appreciate you bringing that up. And again, it’s thinking about that cognitive friction and culture. There’s a huge difference and we all love coming on to shift with that nurse that we’ve been working with for eight years, and we have full confidence when they say.

I need you in this room. You drop what you’re doing, you come in the room. That type of environment and that safety net of having a system where you just, everything is smooth. The machine is so well oiled. And I think I just wanna highlight again that what we’re working to combat here. Isn’t our knowledge base.

We all, again, generally know how to provide the appropriate care for the patient. But when you start layering in interprofessional relationships, patient expectations, resource availability, consult culture, transfer culture, all of these things create that cognitive friction that if we don’t do our due diligence in preparing for the shift, we are gonna.

Interfere with muddy the water around or limit our own ability to perform at our, at our highest potential. We all have the cognitive ability to provide care. It’s all these other things that we need to get out of the way in their own right, or at least not get outta the way. Actually, I had rephrased that myself too, be aware of control for and mitigate.

So now that we’ve identified and clarified some of these problems, let’s talk a little bit about solutions. And I’m a simple minded person and I like little catchphrases. So in this space, I like to think about way before day before. Bay before little, you know, a little rhyme in there, something to help you remember it.

And so I’ll explain what I mean here. So way before, so this is probably in terms of, you know, as we get into that mind frame of I work here, I work here, I don’t know, I work in this third location and they’re all vastly different in a lot of the systems and culture the way before part. This one probably takes the most work.

What it is is getting to know the system and its functionality before you ever even start a shift, before you start working there. And a lot of this is gonna be done in. Your and the hospital’s, I guess, recruitment process, right? When you see a per diem job that has great pay, or you’re like, okay, I, I love my academic center, but I also wanna maintain my own tactile skills, so I’m gonna work in this freestanding emergency department.

You’re going to go through that process of understanding the hospital, its systems, your support, and the expectations of you. And this can come together in what I kind of imagine as a quote unquote hospital snapshot. Uh, and it includes things that we’ve kind of mentioned, like what is the consult. Phone tree.

How do you work through consulting your consultants? Is it always in order in Epic? Are you just gonna be dialing it on your hip phone and having them call to your hip? How does that work? What’s the transfer process involved? Uh, what are your stroke pathways? You know, what the specifics related to that?

What specialty services might you have? This is a huge one. As we start thinking about what jobs we wanna work. Do we have ob, am I delivering all the babies that come through the door? GI cards and then stemi, you know, talking about cardiology, STEMI workflows, stroke workflows. There’s a lot of kind of high acuity act efficiently and smoothly processes and, uh, workflows that we need to be aware of.

Uh, Mt. MTI, you know, if you’re gonna be doing massive transfusion, what is your, uh, process there? Uh. More simply than that. What is your airway management structure? Are you working with DL or vo? That’s a good starting point. What is, is there an airway cart available? And then, you know, things like who runs codes and nursing culture.

So if you have those things kind of on your. Piece of paper. I actually love, you know, living documents, things that you can pull up in real time like a, a Google Doc, uh, of this hospital. Having that way before and getting the answers to these questions on a one to two page document that you can reference whenever, that’s a huge benefit to you.

We all probably do a lot of the work in answering these questions when we’re applying for a job or considering working somewhere, but maintaining those notes is actually something that. Many of us probably don’t think to do in the long term, and you actually would be surprised taking a step back, how many physicians who’ve worked in an institution for years or decades and can’t answer some of those simple questions.

Oh, absolutely. And it’s kind of funny that you mentioned this because, um, a living document like this was actually one of my creations when I worked at my previous full-time job. Um, we had residents who came into our community site from Jefferson and they would rotate with us for a couple weeks, twice a year and one year at a site that infrequently.

This is not the thing that is in the forefront of your mind. So I created a living Google document that had everything like this from what services do we have available to, who do you call for this? And even simple things as where do you go to pee? Where’s the closest bathroom? What are the door codes for the storage closets?

Um. And I’m at, you know, I just started my new job this week and despite having been taken on a tour of the main hospital multiple times and been taken to like our personal break room, I got in there on my first shift without anybody, you know, looking over my shoulder and went, oh. Shoot, I don’t actually know the door code to the break room because somebody else had been keying it in every single time.

And it’s like, well, do I ask, this is kind of embarrassing, I should know this by now. But on the other hand, if you have something like this, it makes referencing it all the much easier, and a lot of these questions don’t come up until they come up. While everyone may have thought that they did an excellent job of telling you all of the quirks in the hospital system, there are things that slip through people’s minds until they happen.

In reality, for example, I learned on shift that during banker’s hours at our main hospital, STEMIs are not seen by the emergency docs. They’re taken straight to the cath lab if they’re called pre-hospital, and that’s, that’s a great workflow. That’s something that is not necessarily at the forefront of everyone’s minds when they’re touring you through the department and saying, here’s where our workstations are.

Um, so I agree. This is the kind of thing that every department should strive to have for refreshers, for the docs that have been there for 30 years, for the ones that are gonna be there for 30 days. As a locums physician, no matter where you are, this is key to kind of help making your everyday life just that much easier.

I appreciate that. And even the important just, uh, necessities of life additions. You know, we wanna know how to initiate a massive transfusion, but we also wanna know where the bathroom is. Uh, do you have a cafeteria? Uh, if there’s cafeteria, what are the hours? And then even the simple things like those door codes, you know, having your Google doc there.

And be like, oh, they changed the code. I’m gonna pop in real quick, change it, you know, 1 3, 1 3 star. That’s what it is now. And you can carry on with your day. But you know, it would be, it’s a tough situation when I’m preparing for this Halo event. I gotta go pee real quick and I can’t remember the door code.

What a cognitive load that you could remove from that space. And you know, I agree that it’s a responsibility both of. The medical director trying to bring you on board of providing you all this information, and that’s awesome that you’re giving that to the residents. So they were, you know, ready for just the learning side.

Forget all of the operations elements, just have the learning available to them. You get these documents when you apply for the jobs, and usually they’re three, five pages long. Taking that and dissecting it down and minimizing it to something you can reference quickly and have that foundational knowledge and document to reference.

Okay. It’s been actually three months since I’ve worked per diem at this location. Let me pull that document back out. And in our show notes, we will have structures for people. You can download this document and just start implementing this with the jobs that you already work or when you’re applying or considering, you know, entering into a new per diem or locums or you know, critical access hospital.

You can build this way, way before document so that you’re ready to kind of hit the ground running.

Yeah, I agree with that, and I highly recommend that you utilize the resources that we’re going to provide to you. I have started things living in just the notes folder in my iPhone, which is great, but at the same time, it’s harder to section out and when you have something with a structure, again, that’s just a little bit less.

Off of your cognitive workflow to immediately be able to page down to the codes page instead of scrolling through my original documents that may have the door code halfway through, and I can’t even find it when I need to have it. So structure is key. Yes. Structure and repetition, right? The ability to just use the same, same structure across different environments.

What we can take and make. Same, just again, as you said further unloads us. Um, all right, so that’s the way before, that’s the foundation. That’s the knowledge that we should all have. If you don’t have the answers to those questions readily in your brain for the place you’ve worked at for eight years, well maybe it’s an opportunity to consider building such a document.

But now I want to transition into the day before element. We had way before, day before and day before. So this is what I think of as just your mental priming. And here, I think, you know, again, our skills in emergency medicine make us probably. Maybe be better at this than some other specialties because, you know, we’re in this preparatory phase and we do this a lot, in a lot of different capacities, whether it’s transitioning in acuity, transitioning in environments, but um, we in emergency medicine, you know, we have to be the chameleons, uh, for lack of a better descriptor.

In that space, right? We have to speak probably 15 different subspecialty languages. We have to relate to patients across a wide swath of both educational and socioeconomic spectrums. We’re kind of built to blend in, and so in this kind of day before exercise, we’re mentally rehearsing the type of provider that we need to be.

Spend, you know, five, 10 minutes the night before thinking about. Structures and we’ll kind of, uh, for the exercise, let’s break it down into the spectrum of care we can provide. So, all right, tomorrow, I’m in my critical access hospital, so. I need to be thinking a lot about early transfer decisions. I don’t want to be resuscitating someone for an hour and a half and then place my page out to the academic center or tertiary center that’s gonna accept them.

I am procedurally independent in this space, right? So I’m the guy for doing, or gal for doing the dis, the dislocations reductions for floating the pacer for whatever it is. Same in the airway, right? We don’t probably always have. Anesthesia backup at that critical access hospital. The amount of blood products I have might be limited.

Um, you know, there’s the potential to manage uncertainty of patients for longer periods of time. So let’s take that hat and put it on our head when we’re gonna be going in our cri critical access. And then to kind of hit the other side of the spectrum. All right, tomorrow’s my academic, tertiary, quaternary, silver tower, uh, center.

So now I need to be ready for teaching, uh, as an overhead or like a element that’s. Gonna be a huge part of what I do. I have to manage multiple consultants and keeping them happy and making sure I get the right type of hematologist for this patient case, that subspecialty nuance. Uh, there’s oftentimes in these big centers, the complex social or the boarding issues that come on and throughput oof that one gets me sometimes in the tertiary spaces.

Throughput is oftentimes slower. So just as an example there, putting that mental hat on for five, 10 minutes the day before doing a mental walkthrough, five minutes or so, uh, working through some complex cases can be really helpful. So we put that hat on. Okay. Here’s my. You know, uh, freestanding er, here’s my academic center, and then let me just do a complex case.

In my mind, in that environment, a crashing airway patient, how am I gonna manage that? What type, where is their airway box? Who’s do I have anesthesia or not? Am I managing the vent? Or will the ICU be down at bedside briefly? A septic shock case, right? Okay, now I have my stemi, am I in a thrombolytic area or am I gonna be trying to rush to get to PCI?

Uh, other ones could be simple, just social problems. Are there, uh, shelters in the area that I can discharge this patient to, or am I gonna consider keeping them overnight? ’cause it’s, you know, five degrees out and there’s nowhere to go. So. Those things come into it and it really helps put your brain kind of in the trenches, so to speak, and makes dusting the process off easier and, uh, less painful when you sit down in real time.

Absolutely. And to your point, I think it’s important to do it the day before and not on the way to this shift. For one, if you’re like me and you work at, I could be at any of four different hospitals. It reminds me which hospital I actually have to drive to. They’re not exactly close together. Um, but two, if you do it before the shift, you are gonna give yourself some anxiety or dread or even just you’re gonna start the shift keyed up because you’re already mentally working before you’ve even gotten there.

And our jobs are go from the moment we. Get in there, we’re already at a hundred percent, and so being able to go in calm and relaxed is better, and you’ll be more calm and relaxed because you’ve already run through all of the possibilities of what can happen that might add to your cognitive burden today.

So on your drive-in, you can do whatever makes you happy, listen to a podcast, drink your coffee, what have you, but you’re not already worrying about the things that could go wrong. You took care of that already. I appreciate it and like that as well because you know, in our busy lives, if you have kids, you have other competing interests, you, you might put that off.

And I think the time and the drive in, I share that same perspective where I’m usually listening to EMA or something else that’s. Intellectually stimulating and get getting my critical thinking emergency medicine provision of care, brain on, and like we said, not the time hopefully to be doing the, where is the thing, where am I going?

What are the directions? Where do I park? Part of stuff. So again, remember we have our show notes where we have some structures here. So we had our way before. We have some questions and things you can put together for your day before. Now I wanna talk about the Bay before and, but this really, I mean, it’s kind of the first 15 minutes.

I ideally, before your start time, as Liz mentioned, you start at 10, you gotta be there at 10, ready to see patients. So if you can get that 9 45 arrival time leading up to your actual clock in, that is ideal. And I think of this one as a pulse check for the department, but also really for me, if I don’t work there commonly.

So what are we doing in kind of our bay before space? We’re asking a handful of questions and I actually like to physically walk around and just touch. I know it doesn’t necessarily change where it is. I still, I could do it mentally, but just, okay. Where is the ultrasound machine? I’ve touched it. Oh, let’s verify that it’s actually been plugged back in and that the probes are clean.

Where are my airway supplies? What’s the boarding status? Who is my charge nurse? And have I worked with this individual before? Do I have to introduce myself and see if there’s any quirks or things I should know about the department going in? So that kind of puts your brain in the department, and as I mentioned, physically walking around helps with both that cognitive load of that orientation process.

It just makes you feel more at ease. Here’s my endotracheal tube, my bougie, my scalpel. I’m gonna put a little rubber band about around that and just have that ready to go. Right? Their central line kits here have the flushes internal. Fantastic. I’m physically touching these elements, so having the equipment spot check will help you feel like you’re grounded again in the space that you’re working and.

Within that we, you saw with our sort of day before, we’re doing the mental modeling and then we’re doing a little bit of almost like a mental role play. And in this situation, in that bay, before those first 15 minutes, doing a little cultural calibration after that exercise of walking around, introducing yourself to charge nurse, getting a sense of the boarding situation, but a cultural calibration of things like.

What do I have to think about transferring here? You know, what tends to get sent out early? What consultants want from me in this space before I call them or before they accept the patient? What might frustrate my hospitalists most when I’m calling to admit someone here? So that little cultural pulse check too can be helpful.

In addition to that little bit of a physical walk around, I find.

I agree with all that. And I think one important, I think that one important thing to add to your physical walk around is to walk around to these sick patients and your sign out patients. Um, this conversation, you know, which, you know, Jason, but everyone else doesn’t know, was triggered by a really horrible sign out that I got in a not quite critical access hospital, but a rural community hospital with.

What turned out to be a fairly unstable patient that we had depleted all of the departmental resources for, and I had no physical way to transfer and turned out was undermanaged and was crashing. And I think that as an attending, sometimes you get to a point, you know, especially with colleagues that you’ve worked with a long time and you trust where you go, okay, like, you know, I trust your sign out and I’ll just see the patient when the labs return or whatever.

But that. Is a false sense of comfort that we get into far too often. We’re all human, we’re gonna miss things. Patients’ status changes. And so I think it’s really important to go around and see these sick patients in the department, your sign out patients, so that you’re calibrated to what their baseline is so that when things change, that’s one less question that you’re asking yourself.

What were they like before? And now you can go straight into. Their airway is deteriorating. Well, I checked on them before. I know they weren’t like this, so now I know that I need to intubate them. And I went through this already, so I know that the airway cart is fully stocked today, and I’ll bring it right over.

I, I agree and I couldn’t appreciate more that that additional element, which again, as you talk about it, there’s a consideration and recognition of culture, but. I think the, there’s a huge amount of importance if you’re receiving sign out in some of these patients where the shared eyes really, really matter, uh, in some regards.

So rounding on or physically seeing the critical patients, one, introducing yourself if there’s a family member there who’s trying to figure out. Is this, is my loved one gonna go into the ICU and now they suddenly have a new doctor. That, that’s a huge thing that we can, you know, remove some of that trepidation and show a shared model, uh, as a department.

And then two, you know, the, the altered mental status patient. You know, is this a delirium or is this their underlying dementia? Let’s go in together. Have you introduce me. Quick conversation. Okay. Doctor, sign out. Yeah, they look the same as before. Doctor sign in. Okay, now I have your baseline. Or they’re doing really well on BiPAP.

You know, we all have different thresholds for what doing really well on BiPAP is. And you don’t wanna walk in the room and be like, is this really well from their perspective or are they suddenly way worse and I should have put a tube in five minutes ago? That type of stuff is invaluable, uh, in that sign out.

If that culture doesn’t exist, I would argue personally that that’s an opportunity to help maybe have a shift in culture because it’s gonna improve the quality of care that you provide so much. So great addition. Thank you. Yeah, and I wanna expand that a little further too. Um, when we’re talking about culture calibration and what’s the culture of the hospital, another thing to think about is what is the culture of boarding patients?

We can’t avoid it. We all have it, but what happens to that sick boarding patient that is sitting in the department whose name is attached to it? Is it yours? Even though they’re admitted to the hospitalist, if they crash, who’s running that code? Is it you? Mm-hmm. Does your department respond to codes in the ed, even if they’re already admitted?

Those are important things to think about and not the thing you wanna be finding out as the charge nurse comes running in saying the patient’s braiding down. Yes. Yeah, good point. You code status is a great starting point there too. Uh, but yeah, that’s a, a reality for all of us, the boarding status and, you know, knowing in that space.

And I, I think that this is probably in the way before. Although you might need to put it into your sort of day, be before review of what does the hospitalist do in the department, as you said. So you have, you know, five borders and two of them are pretty sick. If you’re running around providing care and a nurse comes to you asking for a diet order, or Hey, the patient’s complaining of chest pain and you ordered the EKG, who’s gonna review the EKG?

Who’s gonna reexamine that patient? Does that responsibility fall on you or. Is there a hospitalist that is actually coming down and seeing changes in status patients that are, that are there boarding? So another fantastic addition. So the final thing I want to talk about is what I’d call maybe high yield habits for the multi-site physician.

Sounds like the title of a book. Um, you know, things that we can do for physicians as physicians that. Work in different environments. And the question comes as kind of when can we, or should we standardize our own practice? Or I guess you even say like, core principles of what we like and do, uh, when we’re providing care.

And this could be things like our mental model for sepsis patients. You know, how quickly do you get your antibiotic, uh, order in? Are you waiting to do your. Examination, determine a potential source and then or wait for labs before ordering. You know, the timing for that repeat lactates, those elements.

Your individual airway checklist and the line in the sand that you place for doing a cricothyrotomy. What are your go-to RSI Drugs, you know, are you a X and uh, ketamine person? Do you love rocuronium? Can you have that stuff? Set for all patients and even your own documentation culture because. In addition to performing well in all these environments, one of the ways to keep these shifts and shift changes from being overwhelming or something where you just stop doing that per diem work, is staying on top of your charts and getting out on time.

And so, you know, see the show notes. We have a re uh, recommendations and structure from prior podcasts that you can use. But having that. Documentation culture for you individually, so you’re on top of notes. That’s a standardization, which again, removes all of these variables. And then finally, how good are you at keeping your closed loop communication going?

You know, do you know the names of the nurses in the space? If not, can you make eye contact with someone, make a request, receive their verification, and carry forward? So that’s hugely important when you’re working in environments where you might not know everybody. So any opportunity to standardize your own practice or core principles, I think is really valuable.

I agree. I think all of that is really important and I think that’s what helps you. I think that is what helps put you in a really good mindset for going onto a shift and feeling prepared so that when these events happen, when we have a sick patient, when we have a halo procedure to perform, when we’re really stretched the limits of our.

Abilities and what we need to do, the type of physician that we need to be having a regimented routine, um, and having good communication can be the difference between having that go very, very well regardless of patient outcomes versus feeling in a state of panic and having detrimental side effects.

Whether it’s how you feel personally after the procedure, how the patient did, the culture of the staff around you, how they react to everything when everything is. Routine. The unexpected can be more reassuring because you already have the mental capacity to handle something a little extra. If every day is a little extra because you’re not sure of where you are and you’re not sure where the code card is and you’re not sure where the charge nurse is, then when bad things happen.

They feel all that much worse. Mm-hmm. Yeah. All of those little differences become, it’s a death by a thousand paper cuts. Right. Uh, they become insurmountable when you start your day with 15. Challenges or cultural, uh, shifts or cognitive friction as we talked about in the beginning of the podcast, that are system level things.

And by doing our way before, day before, day before process, we can remove. 12 of those 15, we’re not gonna say that. It’s always gonna be perfectly comfortable transitioning and being that chameleon in many different practice environments. But if you can remove the vast majority of those burdens, the couple little quirks, you figure ’em out, you know, in the first half hour, 45 minutes of your shift and then you’re ready to practice medicine.

And Liz, I appreciate your bringing to the fore a little bit about sort of. Stress management and and mitigation. And I actually think it’s worth talking briefly about structures there because we’re talking a lot about creating structures and doing some mental modeling as we prepare for these shifts and for those who are interested.

Our very first podcast was about a self ignited individual in a remote access hospital where I was on my second shift there and had to do a crike and I was the only. Provider in the hospital. So if you want a real life example of how this all kind of came to the fore and the. Driving factors of these types of conversations that, again, will be in the show notes, but we talked a little bit about stress mitigation in real time in that environment.

So say you’ve done your, you know, pre-work in this space and you’ve mitigated the vast majority of the systems level cognitive friction, and now you have a critical case in your remote access hospital. I’m just gonna briefly. Put a structure that you could probably mental model in your day before for how to bring that stress down in these settings.

And I first think about grounding. So this is the idea. If you have incredibly high adrenaline, you actually can start to get out of body experience. Some people actually feel like they’re physically floating, and so just grounding. And for me, that’s always find your feet close, my eyes, feel my feet and my shoes.

Know that my feet are on the floor in this Resus Bay. It takes a few seconds and you’ve grounded yourself to that. And then others will use mantras, which I also like to have is a individual statement that you can make to yourself that even just like reflexively Pavlovian makes you feel more confident.

Scott Weingart talks about slow is smooth, smooth is fast. Some people just say, stay calm. You got this. Whatever works for you is that little mental trigger that you’re. Badass doctor, and you’re gonna do a great job. Having that mantra to repeat is a nice one. And then the last part is the paras sim, I think of parasympathetic stimulation.

So this is for me pursed lip breathing through three to five breaths, not val, val salving or ling yourself fully out, but a little bit of purse, lip breathing. Slowing your breathing down through three to five breaths with a little bit of pressure to it has that parasympathetic stimulation and can bring that heart rate down even a little further.

So a slightly separate tool, but I think it’s important referencing again in these conversations about remote access, critical access, austere environment care, where a little mental modeling there can help you be ready if the shit really hits the fan when you’re on shift. I agree. I do similar things myself.

I am a big fan of box breathing instead of purse lip breathing, and to ground myself. I start by moving every part of my body. I start wiggling my toes, then my ankles, and I move my joints all the way up to my head. Takes about 10 seconds. But it’s a good way to get feeling in your entire body, but also consciously recognize that you are in control of every single sensation.

I think that one of the things that you’ll find when you are good at, whether it’s you’ve taken the time to prepare yourself or this has become old hat, that even when the adrenaline is flowing, that you start to subconsciously. Learn how to slow your nervous system down. Um, I found that I wear an apple watch and my heart rate does not escalate anymore in critical patients and during codes, my heart rate stays flat because I have spent a long time honing my nervous system to relax during these situations so I can focus on patient care.

However, when I’m stressed outside of work, that does not kick in and my heart rate skyrockets, but it is something that once you start doing consciously, you will start doing unconsciously too, relaxing your shoulders, deepening your breaths, and preparing yourself to take on the challenges that you have been trained to do.

That’s fantastic. I, I love that, that other version of kind of starting at the ankles or toes and working your way up and kudos to you for being able to keep your heart rate flat during recesses. I have a watch where I can keep track of that and I haven’t gone back and, and reviewed, so I would be very interested in other people’s perspectives and I’m definitely gonna check what my, what my pulse rate’s doing when I’m in and out of the bay.

Um, all right. So to summarize for us, I, it is been a, a very interesting conversation for me, and a lot of this, again, is just things that if you don’t think about doing them, you’re not going to execute what might be. Self-evident, uh, parts of what we do in transitioning, uh, the, the, in the care environments that we provide care in.

So by creating this foundation, we are get setting ourselves up for success. We’re removing all of these cognitive frictions that need to be out of the way because patient care is gonna handle a lot of the frictions and cognitive load we already have. Right. So with the way before work, we are going to build an understanding of what our hospital has, what the structures are, all of those elements of.

Provision of care and the support and system within which we work in the day before work, we’re going to get through some of the more nuanced elements of things like how we call consults, what gets transferred, what can I maintain, what resources do I have within my department, and we’re gonna put our mental cap on to just do a brief exercise, uh, related to the provision of care in that space.

And then we’re gonna orient and ground ourselves to the department when we come in those 15 minutes before for that bay, before work, touching the equipment that we know we wanna have mentally ready, that we don’t need to be searching for when a Halo procedure needs to be done. So I think collectively we should recognize that our goal here is to be contextually aware.

Resource calibrated, I guess for a lack of a better term, and sensitive to the culture of the system and the department. ’cause all eds have their own little bit of culture that we need to be conscious of, but also maintain a personal identity that’s stable. You know, we don’t want to change or alter what we think is appropriate care.

And that again, gets into the idea of having your norms and your. Personal sort of expectation set and not waiver on the things that you feel are immutable or, you know, should not be changed regardless of the clinical environment. So if we do all that work, I think we set ourselves up for the greatest degree of success.

I think that this is one of those nonclinical skills that we try and instill into people. During residency, but for various reasons. It’s really impossible to understand how important it is until you set foot in a new environment for the first time when you’re on your own.

And having that core sense of self and having a solid plan again, will help keep you best prepared to handle whatever the day is gonna throw at you. Yeah, I I think that’s an interesting concluding point to recognize is this is. In some ways, one of the hardest things to teach, um, because the prac practical application of it, uh, doesn’t really come to the fore until you are moving across systems.

And if you are a, in a residency program where you do have that tertiary center and you’re getting in the community and getting a freestanding, that becomes easier. Hopefully. Wonderful individuals like Liz himself has made that process a little easier. And you can focus on your learning, but recognizably the.

Location and culture switching that we do is a skill that we all need to develop. So again, take a look in the show notes. We have a lot of great references for doing that process the way before, day before, day before. Things to think about for what are your, uh, immutables, your specifics that are not changeable and core to your practice, and then adapting yourself to be ready for this.

By doing a little bit of that pre-work is gonna make all the, these shifts that much more enjoyable. So, Liz, thank you so much for joining us today.

It’s been a pleasure having you on board and talking about a topic that I don’t think people consciously think about nearly enough. And I look forward to having you join us for future podcasts. Thanks, Jason. I was really happy to join you and I’m looking forward to having you join myself and Dr. Estes, uh, for a continuation of similar conversations about our adventures.

You can also hear an upcoming podcast with Jason and myself on the Women’s Wisdom Podcast through a a b. Fantastic. So when we have that together, we’ll make sure that that is in the show notes as well, so people can check out the great content you’re putting together. And everybody, thank you for listening.