Mental Practice

I just finished reading a paper on the use of mental practice for resuscitation, and I couldn’t wait to write a post. Usually when I find an interesting paper, I put it aside to include in my collection of “articles of the month”, but I just had to give this paper its own post. This paper epitomizes the raison d’etre of First10EM.

First10EM is fundamentally about mental preparation. True emergencies are rare, so it is difficult to develop and maintain excellence. Medical education has turned to high fidelity simulation to help with this problem, but simulation requires time and resources frequently unavailable to emergency physicians practicing in the community. However, the human brain has an amazing intrinsic capacity to simulate real world scenarios. These authors define mental practice as “the cognitive rehearsal of a skill in the absence of an overt physical movement.” In other words, you can participate in high fidelity simulation while relaxing on your couch, on a beach, or even while in the shower.

First10EM is meant to be a guide for exactly that kind of mental practice. As I describe my approach to various time sensitive emergencies, the idea is to visualize exactly how you would act in the same scenario. Where is the equipment stored in your resuscitation room? How many people are normally available to you, and how will you interact with them as team leader? What will you do during those first 10 minutes?

The paper I am talking about is:

Lorello GR et al. Mental practice: a simple tool to enhance team-based trauma resuscitation. Can J Emerg Med 2015;10:1-7. PMID: 25860822 (Free open access article here)

This was a randomized, controlled trial comparing mental practice to usual ATLS training in a group of 78 residents (from anesthesiology, surgery, or emergency medicine). The structured mental practice consisted of 20 minutes of quiet mental rehearsal following a trauma script. They were specifically instructed to visualize how they would behave and function as a team. The control group was given 20 minutes of didactic ATLS teaching.

Right after the teaching or mental practice, everyone participated in a high-fidelity trauma simulation that was video taped. The mental practice group scored significantly higher (21.5 vs 19, p<0.01) on a previously validated scale (the Mayo High Performance Teamwork Scale). To be fair, I am not sure whether a 2.5 point difference is important on this scale, but they certainly did not perform worse. The authors conclude that mental practice led to improvement in team based skills as compared to traditional training.

My Bottom line: (With a very high degree of personal bias.) Mental practice is obviously a valuable way of preparing for high stress situations in emergency medicine. It is something I think we should all be doing throughout our careers.

The specifics of this paper don’t matter too much to me. (When you already believe something works, you are never too harsh in your critical appraisal.) I am not sure if mental practice is better than usual teaching. I don’t know if this study proves that it is. However, this is a free tool that can be used anytime, anywhere.

Any form of education can be done poorly or well. We often attempt to assess simulation as a whole, but all recognize some scenarios and teachers are amazing, while others are lacking. Similarly, we all still remember some outstanding lectures from medical school, but most slipped from our minds before we were even out the door.

Mental practice cannot guarantee great outcomes on its own. One could practice poor technique or mentally simulate in an evidence vacuum. There will always have to be educators or coaches to guide us, but once we have a solid foundation, I think the benefits of mental rehearsal are obvious.

We have an important job. We have a stressful job. We have a job that requires us to be ready for absolutely anything at all times. How you prepare for that job matters.


A simplified approach to the initial assessment and management of patients with LVADs in the emergency department


A 74 year old man is brought into the resus room at your community hospital. He has an altered level of consciousness, but is still rousable. EMS is quite concerned because he doesn’t have a pulse. He does have a large machine sticking out of his chest that his wife tells you is an LVAD. You have never seen one of these doohickeys before. Your nurse had never even heard of an LVAD before. Everyone looks at you expectantly…

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The Harms of “First, Do No Harm”

Often misquoted as a component of the Hippocratic Oath, “first, do no harm” has become a mantra of the medical profession. These words are repeated daily at conferences, in textbooks, on blogs, and in conversations worldwide. They are treated with reverence, as if they provide some great insight. I think they are insulting, misguided, and harmful.

The insult is obvious. These words imply that I might intentionally harm my patients if I am not occasionally reminded not to. I have never met a healthcare provider who would intentionally harm a patient. (If such a person exists, I doubt that a catchy phrase is going to be what stops them.) Those words tarnish the daily toil we all endure, focused entirely on our patients’ well being.

However, the insult isn’t what bothers me. I am a thick skinned emergency doctor and it takes a lot more than a few words to hurt my feelings. The real reason I would like to see those words banned from the medical corpus is that I think they perpetuate a misguided understanding of medicine that results in millions of patients coming to harm every year.

Medicine cannot be practiced without causing harm. Those supposedly sacred words, right from the outset, were a lie. Any treatment that has an effect, will also have side effects. In order to benefit there must also be harm. That is a basic rule of medicine.

This is so often overlooked, I am going to repeat myself. Any intervention that is capable of altering the wonderfully complex machinery of the human body, will have multiple consequences, some beneficial and some harmful. It is the balance of those consequences that makes the medicine. Those four silly words establish a culture of medicine that is forced to ignore this delicate balance of harms and benefits. We are supposed to be perfect. Harms become taboo, and are therefore downplayed.

This minimization of harms in medicine is clearly evident in another common medical phrase: “the risks and benefits”. We talk about the “risks and benefits” of surgery, or the “risks and benefits” of a medication, but this is an inherently unbalanced equation. Benefit is stated as a given, whereas harm is only mentioned as a possibility.

Unfortunately, benefit is almost never a given in medicine. We like to think that all our actions help, but our dirty little secret is the number needed to treat. This is a statistical term that all doctors are familiar with. It describes the number of patients we need to treat in order for one patient to benefit. If every patient benefitted, the number needed to treat (NNT) would be 1, but that is essentially unheard of. In our very best medicines, like using steroids for children with asthma exacerbations, we see NNTs of about 8. That is a great benefit, but it means that for every 8 children treated, only 1 sees a benefit, while 7 are unaffected. Usually, the numbers are much worse. The NNT to save a life by taking a statin (cholesterol medication) after having a heart attack (people at high risk) is 83. In other words, out of every 83 patients for whom a cardiologist prescribes a statin, 82 will never see a benefit.

We balance these ‘certain’ benefits by talking about the ‘risk of harm’. Sure, there might be side effects, but those only happen in a handful of people. What does that matter when we are assured a benefit?

The culture of ignoring harms extends beyond the bedside and into research as well. Studies are designed to search for benefits. Therapies are approved based on research that only reports benefits. We then rely on postmarketing surveillance to try to identify harms. Every doctor knows that initial reports of new therapies systematically overestimate benefits and underestimate harms, and yet we rely on these reports to guide our practice. We can’t talk about the potential harms, because we, as doctors, must “do no harm”.

Finally, the culture of “do no harm” seeps into our assessments of patients. We suggest tests for deadly conditions, no matter how improbable, because to miss such a condition would be the ultimate harm. We do not tolerate misses, because this culture requires us to be perfect. At the same time, it prevents us from adequately discussing the downsides of this over-testing, because if it were harmful, we as physicians would certainly not be suggesting it.

Doctors understand that every test and every treatment that we offer represents a balance of harms and benefits. Unfortunately, the popularity of those four words has obscured that fact from many of our patients. The culture of “first, do no harm” has generated unrealistic expectations of medical therapy. We believe that antibiotics will always cure this cold, but will never cause harm. We immediately recognize the advantage full body CTs but rarely consider the harms.

There is no such thing as medicine without harm. Medicine is about making hard choices; balancing a potential for benefit against the ever-present potential for harm. “First, do no harm” is either a self-evident cliche, or it is a pernicious distortion of true medical practice. Either way, it should be abandoned.

VP shunt malfunction

A simplified approach to the initial assessment and management of sick patients with VP shunts in the emergency department


A 4 year old presented to the ED with a mild headache, nausea, and vomiting, and was triaged to the sub-acute area of the department. You are called to the room stat, as the child is now unresponsive with a HR of 55, a BP of 167/65, and a sat of 96% on room air. His mom mentions that he had a VP shunt placed when he was younger, but now has no medical problems. The closest neurosurgeon is 45 minutes away, if everything goes perfectly…

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Undifferentiated hypotension

A simplified approach to the initial assessment and management of patients presenting to the emergency department with undifferentiated hypotension and shock


“Doctor to resus 2, stat”, and you just stepped into the department. There hasn’t even been time for a sip of coffee or a washroom break after the commute in. In the resus room, you are greeted with a hub of activity – nurses, paramedics, and medical students everywhere – surrounding a 50 something male, rather grey in colour, with a blood pressure of 63/37…

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Local anesthetic toxicity

A simplified approach to the initial assessment and management of emergency department patients with local anesthetic toxicity


You are looking after a 30 year old woman with an isolated femur fracture, and decide to help manage her pain with a nerve block. Unfortunately, your ultrasound machine was broken so you attempted to do the femoral nerve block blind, using bupivacaine. Shortly after injecting the anesthetic, she complains of a headache, dizziness, and numb lips. Then she loses consciousness. You glance at the monitor and notice a wide complex tachycardia.

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Procedure: Lateral Canthotomy

A simplified approach to the initial assessment and management of emergency department patients with retro-orbital hematoma requiring emergent lateral canthotomy


A 21 year old man was minding his own business on a street corner, when out of nowhere two dudes just jumped him. His primary injury appears to be to his right eye. He is complaining of a lot of eye pain and blurred vision. On exam, you note proptosis and an afferent pupillary defect. The opthamologist is covering at another hospital and is at least an hour away, but suggests you go ahead with the lateral canthotomy…

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