Overcoming Adrenaline
25th October 2019
You get the call. Whether you are a seasoned Responder or first aider in the workplace, you weren’t expecting it. If you happen upon the casualty in the street, you certainly weren’t expecting it.
At this moment a chain reaction of events begins to unfold.
Phase 1. Your amygdala - which is responsible for emotions - sends a message to your hypothalamus – which is responsible for regulating hormones - that shit just got real. Your hypothalamus then sends signals along the sympathetic nervous system to the adrenal glands, specifically to the adrenal medulla, which secrete adrenaline and noradrenaline into the blood stream. Adrenaline raises the heart rate; noradrenaline raises blood pressure. You can feel your heart pounding in your chest.
You now only have a couple of seconds to take back control.
Phase 2. If the fear continues for more than a few seconds, the hypothalamus-pituitary-adrenal axis is activated. The hypothalamus releases a hormone called corticotropin releasing hormone, which stimulates the pituitary gland to secrete adrenocorticotropic hormone, which in turn stimulates the the adrenal cortex, to produce cortisol. Cortisol, among other things, increases the supply of blood glucose to make more energy available, enabling the ‘fight or flight’ reflex.
The fight or flight reflex is a primordial response to fear, originally designed to get us out of trouble but now largely sends us into a blind panic. Your muscles are fueled with energy and our ability to make rational decisions diminished, instead we make rash, emotional decisions. Badly.
Adrenaline is preparing us to do stupid things quickly.
The most simplest of motor skills become a challenge as you wear the ‘boxing gloves of panic’*
(like trying to quickly get dressed when you hear their partner arrive home early).We lose our peripheral field of vision focusing on the cause of the anxiety – known as ‘object fixation’ (1, 2)
We lose our ability to multi-task or retain situational awareness. Now all you can think about the cause of the anxiety. (3-5).
We make emotional decisions rather than considered decisions (6-8).
We lose our ability to solve problems, instead we keep trying the same thing again and again despite repeated failure “why isn’t this working!!!” (9-15)
*courtesy of Jamie Jones.
There is hope.
It is possible to overcome the initial response to Phase 1 and prevent the development of Phase 2.
Both adrenaline and cortisol play a very powerful role in regulating the strength of memory by regulating the release of noradrenaline in the basolateral nucleus of the amygdala. Stress and fear can help us re-learn new automatic responses.
If we persistently and routinely practice these steps, especially with additional stressors in realistic settings, we can learn to be effective in challenging situations.
1. Glove Up.
Way before you have even thought about the Scene Survey or Casualty Assessment, Glove up.
You are in Phase 1, your heart is thumping but that’s OK. If a loud bang or the sight of blood did not get your pulse to rise even just a little bit there is probably something wrong with you. This is a good thing AND we can prevent Phase 1 becoming the uncontrolled Phase 2.
On all of our courses we constantly repeat the action of Gloving Up, not talking about it or pretending to do it but actually gloving up for each and every scenario.
Repetitious action develops muscle memory (or more accurately procedural memory) which is stored in the basal ganglia and the cerebellum. We want this to be an automatic response to that crash / bang / scream.
It should be the first thing you do.
If we develop that automatic response to hearing a crash / bang / scream we will instinctively reach for our gloves. The action of putting on gloves in more than simply aseptic technique or a barrier to infection, it takes time to put on gloves, so this is also your thinking time.
Take a breath
Take another, deeper breath.
Deep breathing sends a message to your hypothalamus to chill the f@#% out. (16) This is fine. You got this.
This is your opportunity to capitalise on the increased blood flow of Phase 1 without unleashing the emotional carnage of Phase 2.
In the same way that presenters perform 'grounding techniques' or actors perform short rituals before a scene, the familiar repetitions action of calmly putting your gloves on activates the basal ganglia and cerebellum, where these procedural memories are stored.
But what if you don’t have gloves? It is not reasonable to always have gloves on you at all times. If you find yourself in a situation and have religiously drilled in the routine of gloving up, you are now stood there like a plum thinking “What do I do?” It doesn’t matter what you do. Standing there like a plumb and taking a breath is almost always safer than automatically rushing forwards into danger and the very thought of putting on your gloves has kicked started access to the procedural memories.
2. Rule out what you DON’T need to know.
When you are called to, or happen upon, an incident, it is possible for every single scenario to begin to play out in your mind - a whole world full of panic-inducing "what if's?"
Hopefully you will have received some basic information, if not, a quick scene survey can help. Quite simply, "what am I dealing with?"
The casualty will either be
Conscious or unconscious
Trauma (injured) or Medical (ill)
You now have a simple decision-tree to or algorithm (e.g. (C)ABC or SAMPLE) to follow. The reason we train and deliver care using simple algorithms and drills is that they make cognitive processing easier and more effective in situations with time-pressure (17-21)
Which ‘drill’ are you going to deploy?
3. Perform a Rapid Assessment
The Paediatric Assessment Triangle is a rapid diagnostic assessment tool for infants and children who may be non-communicative or not able to verbalise the problem.
It is also an extremely handy tool for gaining a rapid assessment of the casualty from a distance (yes, that’s right, we still haven’t got to the casualty yet).
By looking at the casualty’s Appearance, Breathing and Colour we can begin to make some quick, simple assumptions about their state of health without getting drawn into the complexities and details.
Appearance – how do they look? Poorly people look poorly. If your casualty is responsive we can assume their neurological functions are intact, we can probably rule out massive trauma, substance misuse, psychosis…
Breathing – from a distance you shouldn’t notice obvious breathing. If their breathing is obvious – it is audible or they are posturing – that is bad. And if their appearance looks like shit as well, that is really bad. We are probably thinking Medical – so we are into our SAMPLE.
Colour – if the casualty’s skin colour is normal, they are full of blood and oxygen. If they look pale but their Appearance and Breathing are normal, they might just be a bit cold. If they are pale and Breathing is not normal, they are probably missing oxygen. If they are pale and their Breathing is not normal AND they look like shit they are probably missing blood and oxygen. If they look dead, they probably are or soon will be.
A quick diagnostic tool should get your spidey-senses tingling. Are they Big Sick or Little Sick?
Developing heuristics or simplified decision-making tools like this require less neurological energy and fewer cognitive resources (19-21) which can enable us to make quick, accurate decisions even at times of heightened stress. (22-24).
4. Talk through your actions
If you have ever learned any motor-skill you will at some point have picked up some verbal prompts to help you.
“Righty tighty, lefty loosey”
“Right over left and under, left over right and under”
“The rabbit comes out of the hole, around the tree and back down the hole”
“Grid to mag, add. Mag to grid, get rid”
“Mirror, signal, manoeuvre”.
Both cognitive and motor functions are controlled by the frontal lobes, cerebellum, and basal ganglia (where the muscle-memory is stored). They interact through feedback mechanisms called corticostriatal loops (25) to control intentional movements that require higher levels of cognition. (26)
Talking through your actions literally tells your hands what to do.
5. The Get Out Of Jail Free Card.
If you make a mistake, start again.
If your mind goes blank, start again.
If anything changes, start again.
Your ABC Accident Procedure directs the responder to approach issues on order of importance.
If you make a mistake, start again. You will quickly recheck everything you have done before to make sure the more important aspects are still in check, get to where you made the mistake, correct it and carry on.
If your mind goes blank, start again. Resetting from the beginning will allow you to regain momentum and refocus your muscle-memory giving you the inertia to punch though that mental block.
If anything changes – the casualty goes unconscious, they regain consciousness, they stop breathing, they start breathing…. Start again. You now have a different casualty so start again. You will quickly respond to the change in situation without deviating from your, by now, well established drills.
Summary
A couple of simple strategies can help improve our performance when it all seems like it is about to go wrong:
1. Take your time.
Take time now rather than wasting time later.
Time spent managing adrenaline now is not time wasted making and correcting mistakes later.
Time spent now is not time wasted making bad decisions later.
2. Rule out what you don’t need to know. You do not always need to know everything all of the time.
3. Perform a rapid assessment - a quick assessment of ‘assumptions’ will give you a broad idea of what you are dealing with. You don’t need to know the detail immediately.
4. Talk you way though your actions.
5. If in doubt, start again. Going back and reassessing a casualty’s vital signs is never the wrong thing to do. Ever.
The more time we spend learning activities and thought processes in stressful situations, the better prepared we become in behaving purposefully in those stressful situations.
Train like it’s REAL, because one day it will be.
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