Here is my SMACC 2013 talk, ‘How to be a Hero’.
Please note I have no pretensions of being a hero myself. This title was given to me by the SMACC conference organisers, and preparing it was an interesting journey for me.
I believe that effective resuscitation requires control of ones self, the environment, the other team members, and the patient. The hero talk focused on managing yourself.
In our daily routine this is no challenge, but in life, circumstances will occasionally arise that demand us to dig deep into our cognitive and emotional reserves to perform under pressures that will tempt us to buckle and to fail and to give up, but when to do so will result in catastrophic consequences for a fellow human.
Acting to help others in tough situations can be considered heroic, and there are clinical examples of this, which I cover in the talk. I first describe a prehospital case of airway trauma, in which UK-based HEMS doctor Ed Valentine responded from home in his own unpaid time to an injured motorcyclist, and carried out risky advanced airway intervention at the roadside. It could have gone wrong, and Ed could have been criticised; the easiest thing would have been to allow the helicopter paramedics to ‘scoop’ the patient. However Ed firmly believed the patient might not survive the journey, so he decided to act. He made an immediate decision, and not acting in his mind was not an option.
Was this heroic?
Definitions of heroism can vary and can be hard to pin down.
I thought I would ask an expert. And who are the experts on heroes? Three year old boys:
That was my son Kal (or ‘Super Kaaal’ as he describes himself in the video). And here’s another definition:
Heroes do the right thing in difficult circumstances, often weathering personal risk to help others with no expectation of personal gain. They are guided by a strong moral compass and persist despite setbacks, often overcoming fear to achieve a goal, accepting the consequences of their actions.
So heroes have a vision of how they should behave, they are ready to act, and they are able to act despite adversity. So yes, Ed’s case was heroic. But is it because Ed was born with heroism in his DNA, or can you learn and even teach this stuff?
We need to look at the work of Professor Philip George Zimbardo. His was the brain behind the infamous Stanford Prison Experiment in which normal students asked to behave in the role of prison guards became more and more abusive to a similar group of students acting as prisoners. There was also the Milgram study, in which subjects were led to believe they were delivering life-threatening electric shocks to actors but did it anyway when commanded by an authority figure. These experiments taught us that ordinary people can be led by circumstances to perform evil acts, and has helped us understand how situations such as the Abu Ghraib prison abuses can arise. These concepts are explained in Zimbardo’s book, ‘The Lucifer Effect’.
But more recently Zimbardo has made a more uplifting discovery: the converse applies.
His research affirms we are equally capable of heroic deeds given the circumstances and preparation; in a study of over 4000 Americans, 20% of people had acted in a way that met pre-defined criteria for heroism (I asked Prof Zimbardo for the reference for this research, and he has graciously offered to send me the manuscript for the study which is currently awaiting publication).
This suggested to Zimbardo that we may all be capable of heroic deeds given the circumstances and the preparation, and has given rise to the inspiring Heroic Imagination Project, which I urge you to check out and support. It has an enlightening video library which can help you understand many aspects of human behaviour that pertain to heroic acts (and their opposite).
Interestingly, in other research on disasters such as plane crashes, earthquakes and fires, three quarters of victims are too stunned and bewildered to act in the interests of their own or others’ survival, often impaired by acute deficits in perception, reasoning and judgement. About 10% will behave completely inappropriately and ‘go nuts’, behaving inappropriately or even destructively. But up to 20% remain calm and rational, maintain situational awareness, and assist with their own or others’ escape or rescue (Survival Psychology by John Leach)
There’s that figure again – up to 20%. But there is reason to believe that many more could be heroes given the right teaching and mental preparation.
Some further cases illustrate the principle of the right preparation: Dr Roger Bloomer’s prehospital resuscitative hysterotomy case is a good example. Roger and HEMS paramedic Rod Wheatley could easily have just done ACLS on the arrested mother and called it. There was no expectation from any existing protocols to do this procedure. In fact this was only the second recorded prehospital hysterotomy in the literature. But they believed it was the right thing to do. The discussed it en route, weighed up the implications, and persisted in difficult circumstances through to completion of the procedure. They could potentially have been criticised. I think it was heroic, and I consider many circumstances requiring life, limb & sight saving procedures to demand some heroic attributes. I have heard too many stories from colleagues who wished they had acted but failed to. The excuses given are numerous but fit certain patterns. It breaks my heart to hear about the patient not being given the chance they deserved and to see a colleague living with regret.
I’ve even tried to address this by getting the President of the College of Emergency Medicine to co-author an editorial that aims to convince colleagues of the clinical, ethical, practical, and even medicolegal justification for doing these procedures. If these calculations are made in advance, less processing is required to make the decision at the right time.
That might help, but what other factors get in the way? How do we raise that percentage of people who act to greater than 20%? One issue is the Bystander Effect, which some aspects of the tragic Elaine Bromiley case may be an example of.
Overcoming this can take tremendous courage, such as that displayed by Joe Darby who at great personal risk blew the whistle on the US Military’s abuse of Iraqi prisoners because (in his words): “It violated everything I personally believed in and all I’d been taught about the rules of war“.
As a registrar I worked for a neonatal and paediatric retrieval service. My FIRST case required me to attend a term newborn in a private facility with respiratory distress. This baby was profoundly cyanosed and shocked. I was required to anaesthetise and intubate the baby, establish umbilical access and start vasoactive medications. The father of the baby was a paediatrician who had previously worked for this same retrieval service and he stood there looking utterly pissed off at everything I said and did. The baby had persistent pulmonary hypertension of the newborn and required someone to organise nitric oxide to be brought to the hospital (I got the boss in for that bit). The nurse asked me a drug calculation question and I found myself struggling to answer. I was MAXXed out – my cognitive bandwidth was occupied by a mental white noise that was obscuring effective cerebration. Somehow I fought through it. I remember an internal dialogue in which I told myself: “you can do this. You HAVE to for this family. Keep it together. Focus. You can do this“.
I subsequently learned that this is known as positive self-talk. It is used by athletes and by members of military units combatting sudden attacks by insurgents.
It requires awareness and control of your thoughts and emotions – mindfulness and metacognition, and can be practiced and trained in simulation, particularly high stress immersive simulations that have cognitive fidelity. This will mitigate the effects of stress on the performance of your attention and decision making, and build cognitive resilience.
My friend Mick Wilson epitomised the attributes of heroism. A helicopter paramedic, Mick was injured during a winch rescue mission. Back on the ground after a brief period of unconsciousness, he spoke to his patient making sure he was okay, cared for, and out of harm’s way, and provided him with safety equipment and advice. Then Mick closed his eyes again for the last time and died from his injuries. This final behaviour was no surprise. This was who Mick was. Several bravery awards and a career of putting his life on the line for others provides the evidence for that. This is how he could be so selfless even when suffering lethal haemorrhagic shock. The decision had already been made in the PAST.
So what do we need to do if we want to be heroes?
We need to define ourselves by our value systems, and consider what we you stand for and what we are not prepared to accept, no matter the consequences.
We need to weigh up the consequences of our actions for given scenarios now and decide to act now, so that when the time comes our cognitive resources are not consumed attempting these calculations de novo.
We must rehearse our actions through immersive simulation training that provides cognitive fidelity – scenarios that mentally get us ‘in the zone’ and feel real.
We need to maintain situational awareness so that we identify the opportunity to act, and develop what Prof Zimbardo calls a ‘discontinuity detector’ – that spider sense that tells us when something isn’t right or conflicts with our moral (clinical and ethical) values.
By making the decision to act in advance NOW we can avoid succumbing to group inertia and overcome the bystander effect.
And once we start to act we must see it through no matter what the obstacle or distraction. Despite adversity we must maintain a crystal clear vision of our completed goal and through training, metacognition (recognising our thought processes) and mindfulness (awareness in the moment) we must develop cognitive resilience to avoid buckling under extreme pressure.
So are you ready to be a hero?
Who are you? what do you stand for? What are you not prepared to accept, no matter the consequences?
Have you trained the skills you need for life saving interventions?
Have you already weighed up the consequences of acting and not acting?
Are you prepared to take responsibility for your actions?
Will you identify the indications when they arise?
Will you be a bystander or be the one to act when others are frozen by fear, indecision and social pressure?
Will you persevere and see it through despite obstacles, and maintain focus in the face of stress?
Please consider these questions.
Despite wishful thinking, all the verifiable data we have is consistent with one life each for your human brothers and sisters, and that one life is often taken away prematurely by sudden and curable disease processes.
For your patients, their families, and your own peace of mind – live without regret.
Let’s get the number over 20%.
I am SURE you can do it.
I am convinced you are a hero-in-waiting.