Jeffrey Bruckel, MD, MPH, FSCAI; Michael Hannon, MD; Konstantinos Dean Boudoulas, MD, FSCAI

Introduction

Interventional cardiology is a fast-paced and demanding field. Interventional cardiologists are often required to think in the moment and make quick decisions that have lifelong implications for patients.

Decision-making happens in every case in the cath lab, which most often is routine. Other situations or emergencies are more infrequently encountered. The pace at which we work the decisions when we are confronted with them can, at times, lead to an overload of our cognitive abilities and make it seem like we are saturated with tasks.

In this Tip of the Month, we focus on human factors psychology and strategies to deal with the stress of day-to-day life in the cath lab.

Stressful Situations in the Cath Lab

In the cath lab, unexpected or adverse events lead to stress that, in turn, can contribute to cognitive overload, acute stress, mental fatigue, and incapacitation; this may limit the operator’s ability to deal with unexpected events and life-threatening situations resulting in patient harm. In the airline industry, it was previously assumed that pilots would function “normally” in emergency situations. Research showed this was inaccurate, and the industry shifted to designing operating procedures, training, and interfaces with the understanding that in emergencies, the operator’s cognitive abilities may be impaired during “non-normal” situations.¹  

Symptoms of partial cognitive incapacitation include incoherent speech, strange behavior, irregular breathing, pale face, decreased performance, repeated mistakes, or unexpected responses to questions.² This can lead to inefficient or inappropriate behaviors, including action or inaction, perseveration, inattentional blindness or deafness, attentional tunneling, “ballistic” decision-making where consequences are not adequately thought through, or degraded situation awareness.¹

Tunnel vision in crisis situations can lead to a restriction of focus and maintaining a single course of action despite conditions changing. Alternative actions may not be considered, resulting in detrimental consequences. Crisis algorithms and clear communication to the entire team are key. Concepts from pilot threat and error management (TEM) training have been adapted to the medical field, focusing on the “patient, procedure, people” and working to ensure the entire team is aware of the plan. In addition, it assists to level the hierarchy so that the entire team feels empowered to speak up if adverse situations appear.³

Human factors psychology dates back to the Second World War and has been very robustly developed in the airline industry. It is not yet significantly deployed in healthcare settings, but this is starting to change. There have been several studies^{4, 5} that have looked at focus groups of airline pilots and surgeons to apply some of the principles of airline safety to the operating room. Concepts like the “sterile cockpit” can keep the focus on the procedure during critical portions. When issues arise, “crisis checklists” can help approach emergencies in an analytical manner. In a study⁶ where commercial flight crews were asked about the approach to crisis situations, the authors found that the approach could be divided into three phases: crisis preparedness, recovery, and containment interventions.

Decision-making should be a continuous process: Anticipate, recognize, evaluate options, act, and then repeat. Rehearse and practice. Using checklists is a good thing.

Strategies for Dealing With Cognitive Load ⁷

1. Take advantage of external memory.
2. Minimize interruptions and be a gatekeeper for your working memory.
3. Use simple algorithms.
4. Use aids without guilt and know your own weak spots.
5. Pregame difficult decision scenarios and have a backup plan.
6. Channel your supercomputer — listen to your intuition and answer the questions that it raises.
7. Accept your limits.

References

1. Albinet CT, Aubineau M, Valery B. “Cognitive incapacitation: theoretical and methodological considerations.” International Journal of Psychophysiology, 188, pp.54, 2023, ⟨1016/j.ijpsycho.2023.05.138⟩.
2. “Investigation Report, Incident to the Airbus A350-900 registered F-HREV on 4 Feb 2020 at Paris-Orly (Val-de-Marne).” Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA). July 2021. https://bea.aero/fileadmin/user_upload/BEA2020-0065.en.pdf.
3. Hardie JA, Hunn D, Mitchell TE, et al. “Patient, Procedure, People (PPP): recognising and responding to intraoperative critical events.” Ann R Coll Surg Engl. 2022 Jun;104(6):409-413. doi: 1308/rcsann.2021.0193.
4. Gogalniceanu P, Karydis N, Costan VV, et al. “Crisis Preparedness: A Systems-Based Framework for Avoiding Harm in Surgery.” J Am Coll Surg. 2022 Oct 1;235(4):612-623. doi: 1097/XCS.0000000000000300.
5. Gogalniceanu P, Kunduzi B, Ruckley C, et al. “Crisis recovery in surgery: Error management and problem solving in safety-critical situations.” Surgery. 2022 Aug;172(2):537-545. doi: 1016/j.surg.2022.03.007.
6. Gogalniceanu P, Karydis N, Loukopoulos I, et al. “Avoid, Trap, and Mitigate: Development of an Evidence-Based Crisis Management Framework in Surgery.” J Am Coll Surg. 2021 Oct;233(4):526-536.e1. doi: 1016/j.jamcollsurg.2021.06.010.
7. O’Shea J. “Cognitive Load and the Emergency Physician.” emDocs. April 12, 2016. http://www.emdocs.net/cognitiveload/.