Conquering fear during a Neurosurgical Emergency

Abstract

Evidence on the impact of emotion regulation on patient safety in acute situations is focussed on work done in the context of the emergency department.1,2 Research in Neurosurgery has primarily been concerned with the longerterm effects of stress on physical and mental health.3 There is no evidence in literature addressing the immediate cognitive mechanisms of emotion regulation during an intraoperative emergency. Fear is an important survival mechanism in response to an immediate threat to homeostasis.4 The “predictive brain model” describes how the brain functions as a homeostatic organ by processing information through a “bottomup” channel which carries sensory input from lower to higher brain areas and viceversa a “topdown” channel that relays our predictions.5 Emotions such as fear are triggered because of the inherent properties of the stimulus or the cognitive appraisal of the event. Fear triggers identified in the emergency care setting include insecurity, physical danger and the threat of the consequences of one s mistakes and actions.6 Problemfocussed coping and social support were identified as mechanisms to control workrelated fear.7 Another recognised mechanism of fear regulation is reframing an event into less emotional terms.8 James Doty describes a case of lifethreatening haemorrhage during the resection of Medulloblastoma in a 4yearold boy.9 While the anaesthetist was performing chest compressions, Dr Doty was trying to secure a torn vein in the posterior fossa. In that timecritical moment, he used meditation and visualisation of the torn vein to successfully control the haemorrhage. Dr Doty passes on the wisdom on the utility of breathing techniques, repetition of mantras and visualisation to achieve his goals. In a parallel case, Dr Mark McLaughlin gives an account of the first posteriorfossa tumour resection that he performed unsupervised.10 He proposes the use of “cognitive dominance” which is defined as “the situational awareness that facilitates rapid and accurate decisionmaking under stressful conditions and limited decisionmaking time”.10 Dr McLaughlin describes the “unexpected” as the fire triggering the “fear fire alarm.” He advises people to dissect the unexpected event into an objective and a subjective component. He suggests focussing on problemsolving rather than on our emotional reaction and reframing the unexpected from an obstacle into an opportunity.10 Insight into cognitive fear regulation can guide younger trainees in refining their own coping skills. Further research including surveys could identify fear triggers and coping mechanisms in the intraoperative setting. The effectiveness of these mechanisms could be investigated by measuring physiological indices of autonomic activation under simulated or real emergencies. For example, respiratory sinus arrhythmia is an index of parasympathetic regulation of the heart. It has been used as a marker of emotion regulation in the study of cognitive fear regulation strategies in children.11,12 The role of metacognition, or “thinking about thinking,” is recognised in medical education as an important aspect of lifelong learning. We propose that further studies on this topic would be proven beneficial in the development of training programmes that ensure Neurosurgical trainees are adequately equipped to deal with the unexpected.