Month: June 2016

Millennia ago, before cannons and flintlocks, sabre-toothed tigers stalked our ancestors. Like most creatures of prey, Darwinian evolution led us to adapt to threats like tigers. We learned to run from danger or, when running wasn’t an option, to defend ourselves to the end. This was not only a mindset innate to humans, but a complex biochemical response: when faced with danger, hormones flood the body, blood delivery to muscles is prioritized, senses are heightened. This response, the Flight or Fight response, is triggered in a small part of our brain termed the amygdala.

Fortunately, sabre-toothed tigers don’t roam modern-day streets. Our bodies, however, haven’t caught up to this reality; the amygdala is standing ready to superhumanize our bodies should our survival be in question. The amygdala works at lightening speed: it bypasses the frontal cortex, where options are considered and debated based on reason and fact, in favour of instinct. Located deep in the part of the brain we share with prehistoric reptiles, the amygdala causes us to react to stress. Sometimes, that stress can be maladaptive, harming us more than it helps. In that sense, our amygdala hijacks our brain, sending our heartrate through the roof and filling our stomach with butterflies.

If you work in a high-stress environment that demands high performance, the amygdala hijack can be deadly. SWAT team snipers, Navy SEALs, 911 operators and emergency workers all face high-stress situations yet must remain level-headed. The conundrum? We are trained to listen to the amygdala! Pattern recognition allows for fast reactions to new information. Secret service agents scan crowds for suspicious patterns just as emergency physicians can spot a heart attack patient from the other side of the room. This allows our mind to pick out problem patterns that are dangerous – to the president, to the patient, to us – and put us on an instinctive reactive pathway.

And this is where the system falls apart; once the hairs on the back of our necks go up and we have been alerted to a threat, we have to quickly overcome the amygdala and analyze the situation. See, the amygdala overcalls threats. A car backfires, and you startle. A plane has some turbulence, and you grip the armrests. We react a little too often to stimuli that the amygdala interprets as threats, but actually aren’t.

The trick, then, is to know how to control the physiologic response set off by the peptides coursing through your veins once the amygdala sounds the alarm. Rather than react immediately, we must suppress that crocodile-brain of ours and activate our frontal cortex, the part of the brain that makes us smarter than every other species on the planet. Except maybe dolphins, I hear they are pretty smart, and they’ve never voted to leave the EU… but I digress.

Whenever I feel my amygdala taking over, I repeat a calming mantra to myself:

Pause, Reflect, Respond.

The amygdala short-circuits the frontal cortex in favour of immediate, instinctive action. My job is to take that intuitive signal and check it against the facts. I pause. I regain control of my brain, quite deliberately, by switching off the hormonal response. A slow, deep breath in pushes the diaphragm downwards, activating the vagus nerve. The vagus nerve activates the parasympathetic nervous system, reversing the effects of the amygdala hijack. Holding the breath stimulates baroreceptors, sending calming signals to the brain. Nodes in the heart are stimulated to slow, epinephrine is moped up and cleared out, and the fog of fear clears from the mind, restoring the analytic abilities of the frontal cortex.

Alerted to danger and ready to think, the next step after pausing is to reflect. Are the facts that I am seeing congruent with the emotions triggered by the amygdala? Is the threat real? Can I obtain more data to confirm my intuition? Some of this will seem very familiar to work done on the psychology of clinical decision making championed by Nova Scotian Pat Crosskerry, and it is! You can check out some of his work if you are more curious on how health care workers think.
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Now that I have considered the information, I can respond to the situation. Note the word “respond” rather than “react”. A reaction is quick, instinctive; a response is slow, considered. That’s not entirely true… skilled and experienced health care workers can experience an amygdala alert, pause, reflect, and respond, in milliseconds – but only because they have trained their brain to do so.

Pause, Reflect, Respond is of course oversimplistic. Pausing, I find, is incredibly challenging when the stakes are high and a room full of people are looking to you for leadership and direction. Reflecting involves teasing out reality from my own perception of reality, where cognitive and social biases are deeply rooted. Responding requires confidence and ability, something I am still developing as a junior doctor, and negative self-talk, self-doubt and “impostor syndrome” frequently scare me away from a plan of action in favour of deferring to others, a feeling that I don’t (anymore) have when I work on the helicopter (and one of the key reasons I continue to do so). I am practiced at Pause-Reflect-Respond to nearly any situation I come across on the helicopter, but in the emergency department, it’s a different ball game.

Lastly, while clinical analysis is our core job, emotional intelligence is what really gets the job done. Being able to lead a team to achieve the goals required to treat a heart attack patient is as essential as knowing how to identify and treat a heart attack. Pause-Reflect-Respond applies to this realm of medicine also; understanding the state of your team, and being able to modify it to achieve higher performance, is the hallmark of an effective emergency physician.

The amygdala hijack causes smart people to do dumb things. By pausing, reflecting and responding to stressful situations, we get the best of both worlds; accessing our past experiences while analyzing new ones helps us utilize our entire mind to best lead teams to perform at their very best. High performance teams freed of the amygdala hijack –be it on the battlefield, in the cockpit, or in a resuscitation bay – save lives.

 

Are you good at controlling the Amygdala Hijack?

Do you have the tendency to:

-be deliberate and apt to survey a situation before responding?

-control your emotions?

-resist impulse under times of stress?

-describe yourself as emotionally neutral?

-not allow emotions to colour reality?

 

Have tricks to overcoming your fight-or-flight response? Comment below!

Here are a few short writings from my travels through India.

Searching

I first met him laying be bed next to me.  Wait, no, he was laying in the bed next to mine when I first me him.  Aaron Koppenhoefen, a young German sent to India for six months by his parents to find something, though I don’t think he knew quite what.  He looked up from his book and we executed the usual ritual as I placed down my backpack.  I had to come to this ashram in Rishikesh to find something that I was missing; it doesn’t matter what, which is good because I couldn’t explain it if it did.  Six hours north of Delhi at the foothills of the Himalayas is a fine place to be when you’ve got no where else to go.

Aaron was quiet, sitting bolt upright in bed, back pressed so hard against the cold, concrete wall you might think it would otherwise collapse.  He returned to his book, barely tilting his head as his eyes locked onto the words.  I decided to go for a walk to get a lay of the town, some fresh mountain air, and a roll of toilet paper.  It was colder than I had expected it to be and I began scouting around my backpack for a layer.  I found a 100 rupee note and grabbed it along with my forest green fleece.  I put it on and in the process misplaced the rupee note.  I ruffled around, confused, and checked my deep empty pockets.  I turned to Aaron, not out of suspicious or for help but out of exasperation.  Aaron continued reading.  His eyes never left the page.

I returned to my bag and sifted through various currencies until I found a 500 rupee note.  A bit big for buying toilet paper, but it would have to do.  I grabbed my cell phone and a novel (the novel was for appearances sake, really, as even Rishikesh cafes have wifi, and even on vacation it would be 48 hours before my book binding was creased as I instead took time to detach myself from the habit of reading news that was happening 10000 km away). I grabbed my key, stuffed it in my pockets, but didn’t feel the crinkling of paper money.  I sighed, blamed jet lag, and searched my bedding and bag and pockets again.  Then I checked the pockets of my jacket, even thought I hadn’t touched it.  Its funny, the places we look when we loose something.  Such hope, no rationale, our cortex highjacked by our amygdala.  I furiously searched places those rupees could not have been.  A visiting alien might look at me and think I was scrambling for my epipen, or my future, but it was a 500 rupee note.  The note that I had just put in my pocket.  I turned to my new roommate.  Aaron continued reading.  His eyes never left the page.

Exhausted and flabbergasted I returned to my backpack.  I found a 1000 rupee note, which was a useless piece of paper – no one would make change for the 25 rupee tea that granted me a wifi password, or a 10 rupee roll of toilet paper.  I placed it on the bed and by chance pulled out a 100 rupee note, squeezing it tight for my walk.  I grabbed the useless 1000 rupee note to shove deep into my bag (I realize as I write this that I need a more organized way of carrying my money) only to find my hand grasping at air.  I wasn’t surprised, like I almost expected it to have vanished; I didn’t look for it.  I just turned and looked at Aaron.  Wiping any irrational facial hint of suspicion, a skill I take great pride in possessing, I stared at him, still bold-upright in his bed, the wall still erect, his eyes still fixed to the page.  He this time looked up, and I looked into his eyes and his eyes looked into my heart and beyond and I felt naked and cold and paralyzed.  It was like a mixture of curare and Petro-Canada slushie were coursing through my veins in place of warm blood, like the air in my lungs was statically charged and looking desperately for a place to run.  Just as quickly as that sensation started, it stopped, only seconds having elapsed if i had to take my best guess.  Aarons eyes came up to meet mine.  They were massive and dark and through his pupils I saw a sea, or maybe, yes, an ocean, so wide and so deep and so hungry.  “Cant find it” he said, with an intonation masked by his German accent, and despite playing that phrase over and over in my mind, I still can’t tell if his sentence ended with a period or a question mark.  He returned his eyes to the pages of his book, his neck barely turning.

I’m convinced Aaron stole my money that day, but he wasn’t after my rupee.  What he wanted was something I didn’t yet have, for I hadn’t yet found it.  Not my soul, but something close.  I had come to Rishikesh in search of something important to me.  Aaron Koppenhoefen was looking for it too.

Unforgettable

I’ve never seen a cow vomit, but I’ve heard a cow vomit.  It’s worse than you think.

Routine

“1800 rupee”

“Are you kidding?”

“No sir, its a very far way away”

“I could get to Delhi for less than that.”

“No sir, Delhi is much more far away, and the roads are closed, and extra kilometres”

“I’ve been in India for 2 months”

“Yes sir”

pause.

“We have a small car, sir, 1400 rupee”

“I’m not paying 1400 rupee to get to the airport.  I’ll just have to take a bus”

“No sir, the bus is very slow, it is not a good bus”

“I’ll find my own taxi then”

“No sir, very sorry sir, there are no taxis here, only cars from hotel”

“There are 200,000 people in this city and only 1000 of them own a car.  20 tuk tuks have driven by us since I got here.  You’re telling me there are no taxis in Dehra Dun?”

“Well sir, the taxi is not safe”

“How do you think I got here from Rishikesh? In a taxi.  That drove PAST the airport.  For 1000 rupee”

“No sir, 1000 rupee is not possible”

“But I just paid 1000 rupee.”

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“Yes sir”

“Do you have the phone number of taxi services?”

“Yes sir, they are india phone numbers sir.”

“Yes, we are in india.”

“Yes sir”

“Can I speak to the duty manager”

“That is me sir.”

“And you won’t call a regular taxi for me?”

“Sir, there are no taxi in Dehra Dun”

blank stare.

“Ok, I’ll just have to call Sheraton and ask them for help”

“Sir, what time do you want the car?”

“10am.”

“Ok, 600 rupee, and the very best taxi for you, no problem Sir.”

“Thank you.”

//

Varanasi on Fire

Ashes of the dead fill the air, rising up to meet the moon.

Flickers of fire flow slowly by, lamps of grief on floating leaf.

Marchers chant, mourners wail, I stand silently.

Tourists shift awkwardly, invisible to those whose presence has meaning.

Earth meets heaven on the edge of the Ganges; life and death and life intertwine.

Smoke and emotion choke me as I bare witness to the Burning Ghat; it is both beautiful and ugly, both light and dark.  I should stay, and yet I turn on bloc and leave, the smells, the sounds, the spirits chasing me through tight alleyways, past begging children and skinny cows.

//

For more creepy writing, check this out!

For more on life as a backpacker, click here.

“What if you run out of air?”

“Are you sure it’s safe to go to Cairo?”

“Don’t walk around Cape Town at night”

“Aren’t sharks dangerous?”

“La Paz is a bit sketchy, eh?”

“What if the rope breaks?”

“Orlando? Dude, you’re crazy…”

Ok, no one ever said that last one to me.

I’ve written and re-written this post many times in the last few days.  It’s still not right.  But I’m still tearing up when I think about them.  Still getting angry when I think about why.  Still too much in despair when I think about the future of gun violence in the United States, LGBTQ discrimination, legislated hate.  So for now, I won’t write about them, I won’t write about why, and I won’t write about tomorrow.  I’ll write about me – and how what happened in Orlando has shaken me in ways other attacks haven’t.  See, I was in Paris a mile away from the Bataclan that Friday night, and I was in Sharm El Sheik a week before the MetroJet, and I was in Beirut just before a bomb destroyed the lives of people too much like me for my brain to reconcile.  But this?  This time it’s different.

This time I was half a world away in Cape Town South Africa, at a club, on a street, drinking and dancing and singing louder than I ever should.  I was wearing a blue tank top, ripped jeans, and a South African Springbok rugby toque.  When I travel, I party.  I let loose.  I take risks that I wouldn’t take back home.  Most travellers do. From inside that Bree street club, I might have been in any club anywhere in the world.  Even Orlando.  People say I do risky things.  In business talk, they’d say I have a large risk appetite – which to me sounds like I’m hungry for some street meat in Mogadishu.  My tolerance for risk, people say, is very high.  I disagree.
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I think I’m just really good at calculating risk, and that I calculate a lower estimate of risk than most.  This could be the hubris of youth, but I don’t think it is.  I think 10 years of being a professional risk calculator (aka paramedic-turned-physician and world traveller) has strengthened an aptitude for teasing apart real versus perceived risks.  Now, with my desire to live a joyful life competing with my desire to live a long one, my values certainly place adrenaline-releasing experiences over sitting on my couch crocheting.  Still, I think my global travels have taught me lessons about risk that have honed my skills as a risk analyst.

Threats are everywhere, and they are measurable, or at least estimable, most of the time.  Local violence is usually targeted – and not often (but sometimes) at foreigners.  This is why I’ve walked through a crowded Cairo souk during Arab Spring riots but wouldn’t dare visit Mombasa for a beach vacation.

That’s why this weekend has shaken me. By most accounts, what happened in Orlando was a targeted massacre of gay people.  Young gay people.  Young gay people partying on a Saturday night.  What happened in Orlando targeted me.  Only I wasn’t in Orlando – I was in Cape Town.  But I’ve been to Orlando at least half a dozen times, and on each of those trips I found myself in a club.  Drinking.  Dancing.  Flirting.  Not getting shot.

What happened in Orlando is unlike almost every other act of terrorism I’ve ever considered analyzing: it was targeted at me in a place I could have been.

I’m not sure how you feel about what happened in Orlando on Saturday night, but I feel like someone tried to kill me.  Not for my wallet, or my hat, or my phone.  Someone tried to kill me because I’m gay.

So what do I do now? What is an acceptable risk?  And do I accept increased risks as a matter of principle – of not letting terror win – or stick to the objective (though highly value-weighted) math of estimating risk and then reconciling that estimate my risk appetite?  Must I always be “op-on” – exploring everywhere I go with the persona and mentality of an operator? Can I ever really just relax? Travelling is my escape, my escape from a responsibility for making decisions that affect others directly.

Thoughts swirl in my mind as I reprogram my internal risk calculator.  Is anywhere safe these days? Can I party on Church Street, sip cocktails on Ossington, hold hands in San Fran? Do I need to memorize the exits of every club as I enter, have back up plans for back up plans, carry a gun…

And there it is. There is the fear, the irrationality, the them-versus us attitude that terrorism and hatred strives to achieve. An Orlando gay club less safe than walking through a crowd of rioting Egyptians: everyone gear up. I’ll write about homophobia, discrimination, terrorism and how we respond to it soon. Right now, it makes me too angry to even think about.

Answers will come. More questions will swirl. Like the family and friends and community of those lost in Orlando, like every human being with a mind and a heart and a soul in America and the World, I can barely ask the questions.  Who were they?  What could they have been? Why on Earth?  What now?  Am I next?

 

Tell the cab to take you to the General.  Get out on the passenger side; Marvin died getting out the left, silly bugger didn’t call an ambulance when he first felt the pain.  Through the main doors and please nod to Doris; she volunteered at the desk to your right until the day she died, and still today.  She’s much sweeter than she looks.  In front of you is a cafe, but don’t head there; turn left.  Past the benches, down the hall, and don’t mind Seymore, his sense of humour is poorly developed despite is 122 years around this place.  You’ll see a small hall to your right, which is where you would go if you needed an elevator during the morning rush when you are late for rounds, but you won’t need to head the way tonight. Mr Karpf could use the company… he rides that elevator up and down, day and night, “What floor?” with twinkling eyes that should belong to a child, not that old, worn face.  Three short halls on the left; take the second.  You could take the first, find the stairs, but Mrs Kreiger isn’t pleasant at the best of times and I won’t trouble you with having to explain to her where it is you are going (not that its any of her business).  Besides, the stairs to the basement are creepy.  5 elevators, 2 one one side and 3 on the other.  The button will trigger whichever closest, so long as it isn’t broken, in which case it will trigger the second-closest.  Only 8 floors, but they are deathly slow.  Only one of them has anyone inside who you need to be aware of, but its too hard to explain which elevator of a bank of elevators one must watch out for, so take note of a small child who offers to press the button for you; she’s much sweeter now than before the crash. How time can change a little one.  We almost saved her, truly, but she blew an arteriovenous malformation on account of the blood thinner two days before I was going to discharge her home.  Not home, of course, she had no parents anymore… I guess I never thought that far ahead.  Its pointless, you see, to plan your discharges more than a day in advance, as things change.  Brains fill with blood.  Anyways, she’ll ask your floor, and kindly tell her, and as long as its not the 7th or 8th she’ll be able to reach.  Tell her “one below, please” and she’ll be tickled pink.  Now pay attention: there’s a row of buttons on both sides of the door, and you’ll need to be sneaky and press “1 below” on your side at the moment she presses it on hers.  The curved plastic will light up and the doors will closed, and she’ll be quite pleased that she interacted with a world she has no business in any longer.  You won’t have time for chit chat but she’ll curtsey as the doors separate and you can end your relationship with her however you see fit.  Doesn’t matter which side of elevators you rode, you’ll only be able to go the one way.  Turn right, then left, then right, then down a long hall.  If you see “Microbiology” you’re on the right path.  If you see the kitchen, go back to the elevators and try again.  At the end of the hall you’ll see double doors with large metal bars that press to the outside.  Its the first door on the left before you reach this exit.  The door has no sign, no marks, just a small, fogged window in it.  It will look locked; its not.  For some reason, it never is.  My oversight, I guess. 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The medicine is available in the tablets and jelly form. overnight shipping cialis  The small room on the left with the couch is haunted, don’t go in there.  If you sneak a peak you might see AJ wallowing about, who still hasn’t forgiven herself for what happened back in the 70s.  14 years of post secondary education gives you a lot, but not everything, and certainly not what she needed the night she drew the curtain open and spat cruelly ‘is that you’re wife?”.  How we assume… how we err… He hadn’t killed her, you see, but no one in their right mind would have believed it until DNA matches came around a decade later.  Too many bad conversations, too many tears, too much pain. Oh, if I could go back and say it differently, I would, each and every time.  See, you can’t possibly find the words until you’ve experienced it.  Its not so bad, really.  Its kind of, well, nice.  But of course you don’t know that until you know that.  A little further down, and you’ll see 3 large doors leading to three identical rooms.  The one on the left is just storage, see, because there were only ever 2 of us, just AJ and I, and when AJ was gone, the new young girl.  Well, she’s not a girl, I suppose, but I think of her that way.  Vomiting at her desk all day yesterday.  My room was the one farthest from the exit, closest to the row of offices and the conference room you haven’t yet come across.  Through the door and you’ll feel the chill.  The only doctors who wore hoodies at work, we used to joke, until the infection control people got wind of it and started enforcing scrubs.  So we switched to surgical gowns, which only come sterile and cost a fortune – well here I go digressing into politics.  You’re here now, just you and me and more souls than anywhere else in the hospital.  Don’t cringe at the sight of my skin on metal, its no less comfortable than my mattress at home would be to me right now and the perforations actually feel nice.  Cold and dry and lying on a metal table.  38 years I fought the cold of this room, day in and day out, and now it suits me.  11 degrees Celsius.  I appreciate that you’ve travelled this far to serve, I know how little you relish it.  I hated doing AJ, but it was my duty to her, my privilege to loosen the ligature, photograph the abrasion, extract the layrnx.  A privilege that AJ would never be able to return to me, nor I to you.  Anyways, the scalpels and saws and the good pair of scissors should be laid out on the block by the sink.  I appreciate this, really, I do.  You were always the resident who stuck out in my mind even as the years passed and others came and went.  I know that you know this, but in case you are in a contracted state of mind, which you must be, I mean, look at the position I’ve placed you in, please do mind the parts that will be exposed outside the suit.  Oh, and don’t bother with the plastic bag full of explored organs; such a pain it is to fit it back in and close the abdomen, and I don’t want to look pudgy at the wake.  Anyways, I’ll let you get started, so that you can finish.  As I said to you a hundred times, “Why wait when you can make the Y.”  In hindsight I doubt anyone but me ever found that line funny.  “Nurse, the Betadine, STAT’!”  HA! Yes, thats a good one.  You can use it if you like.

Written in Rishikesh, India whist backpacking.  January 2015.

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The dogs always bark.  Its the only thing constant about this place.