Considering human cognitive architecture in stressful medical prehospital interventions might benefit care providers

Traumatic injury is the greatest cause of potentially salvageable years of life lost. Unfortunately, similar to other catastrophic conditions such as respiratory arrest or cardiovascular collapse, most potentially preventable deaths from traumatic injury occur before a victim can be transported to hospital. Thus, diagnoses and interventions to salvage lives must be delivered by first responders outside of hospital.

The TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Consortium has long sought to enable advanced diagnoses and interventions in the prehospital setting, performed by less experienced first responders guided remotely by distant experts using communication informatics. A range of diagnoses and interventions have been shown to be feasible and reassuring in controlled studies.1^,2 Besides helping the patients, this paradigm of care delivery may also benefit the mental health of the care providers. A simulation study in which non-surgeons were remotely mentored to perform damage control packing of exsanguinating intra-abdominal hemorrhage showed significantly increased self-assessed procedural confidence when comparing mentored with unmentored participants.1 Such a creation of a transactive memory system and cognitive offloading should be better understood as a first step in using informatics and remote decision support to improve, or at least not exacerbate, the stress experienced by those performing care in the field.

Stress disorders among those caring for trauma victims are common at every provider level, from first responders to the most experienced trauma surgeons, resulting in so-called “secondary victims.”2^,3 This equates with trauma surgeons having the highest rates of burnout among all surgical subspecialties.4 However, first responders may be the most critical component of the health care system facing great challenges due to mental health stresses. All regular first responders face psychological trauma regularly, with subsequent rates of posttraumatic stress disorder (PTSD) reported to be as much as 10 times higher than that of the general population with at least 1 in 3 suffering.5^–7 This psychological burden is subsequently correlated with high rates of substance misuse, absenteeism and disability, cutting short the working careers of first responders in their prime.7^,8 Classic symptoms of PTSD relate to hypervigilance toward potential threats in the environment and involve alterations to cognitive processes such as memory, attention, planning and problem solving.9 Anecdotally, in addition to the well-understood exposure to terrifying and life-threatening events, catalyzing factors among first responders include self-perceived doubts regarding performance, thoughts of “should have done more,” and ruminating over decisions made that cannot be reversed. As TMUSMI attempts to translate remote telementoring (RTM) support for first responders from the bench to bedside, we consider that human thought processes related to prehospital life-saving interventions (LSIs) deserve a deeper understanding.

Human cognitive architecture in relation to clinical reasoning frameworks can be modelled by dual process reasoning, which postulates 2 distinct systems of reasoning: system 1, representing intuition or automatic thinking, and system 2, representing analytical or deductive thinking.10 Caregivers need to utilize both intuition and analytical thinking to make critical decisions quickly and accurately, as they are often given uncertain and limited information. Both systems are critical, and one is not considered better than the other, although using only one exclusively would be detrimental. For example, when a care provider with clinical experience and confident pattern recognition is providing LSIs using system 1 thinking, further analysis using system 2 thinking would be redundant and could cause a delay in care; however, when this same care provider is faced with confusing clinical findings or when unforeseen complications occur, then system 2 analytical reasoning is critical to avoid error, even if proper care takes slightly longer. This efficient toggling between both systems relates to the concept of cognitive load.11^,12

Cognitive load theory refers to the cognitive resources of a care provider that are required by working memory to make critical decisions or to perform complex tasks. If the cognitive load is excessive, it may overwhelm the working memory, leading to increased stress as well as errors.11 Inexperienced care providers are considered to be at greater risk of cognitive overload, as their cognitive schemata used to organize knowledge and guide cognitive processes are less well developed than those of care providers with previous experience.11 Further adding to prehospital stress and cognitive load is diagnostic uncertainty or the subjective perception of an inability to provide an accurate explanation of a patient’s health problem. However, when cognitive load is shared with other people, such as an online mentor or physician supervisor, a “memory system that is more complex and potentially more effective than that of any of its individual constituents” is initiated, creating a transactive memory system. Within this system, not only are information integration and decision-making processes improved, but a shared store of knowledge is also used and the time required to find and use appropriate knowledge is made much more efficient, essentially improving working memory. A remote mentor or any type of online medical support can be considered to constitute a transactive memory system.

Other high-reliability industries wrestle with understanding cognitive load within the greater sphere of human factors. The U.S. National Aeronautics and Space Administration’s Task Load Index (NASA-TLX)13 describes cognitive load as a multidimensional challenge that can exert itself unevenly across 6 fundamental “demands”: mental, physical, temporal, performance, effort and frustration. For example, a first responder may perform a procedure competently and have manageable cognitive demand; however, if the environment adds abnormally high time or physical safety pressures, then cognitive demands — as well as other associated human factor threats — may surge. Adapted for RTM, the NASA-TLX might allow quick categorization of specific RTM conditions and communication strategies adapted to mitigate the cognitive load demands and ideally balance the 2 systems of thinking. Recognizing these factors might thus help RTM to reduce cognitive load in the short term and potentially help mitigate PTSD in the long term.

Thus, using established frameworks of cognitive architecture may allow speculation as to how RTM might address cognitive load for first responders or any care provider, including residents and surgeons, to preserve their working memory, improve patient care and decrease negative long-term effects. Potential targets for stress mitigation with RTM are listed in Table 1. Given the psychological toll that first responders currently face, study is urgently required to understand how providing potentially life-saving care seems to exacerbate and exponentiate the psychological trauma experienced when witnessing traumatic injuries in others.7 We consider that telementoring will benefit not only patients, who will potentially experience better outcomes, but also the first responders, who will hopefully experience less stress while providing those better outcomes. However, telementoring done poorly can actually decrease performance and increase the stress on first responders,14 so assumptions are dangerous. Therefore, although the diagnoses and interventions that first responders might offer in the future may be dramatically enhanced through telemedical techniques, we have a professional responsibility to understand how this potential paradigm might either greatly benefit or alternatively exacerbate cognitive overload and psychological distress in first responders. We suggest that, as telementoring is introduced, studies should, in addition to assessing effectiveness, efficacy and cost-effectiveness, include measures of the psychological well-being of those using these techniques.

• Accepted September 11, 2023.