Daved van Stralen, MD, FAAP, Sean D. McKay, Element Rescue, LLC, Thomas A. Mercer, RAdm, USN (Retired)
Abstract
The characteristics of abrupt crises are the elements that cause stress and fear. Stress impairs cognition, fear generates defensive behaviors, and existential threat drives aggressive behaviors. Nobody wants this; organizations expend effort to prevent or mitigate stress and fear. Unfortunately, these efforts promulgate and normalize belief in the inevitability of stress. Fear becomes normalized through situationally accepted behaviors such as anger and intimidation, creating the ecology of fear. These same stress responses, fear reactions, and amygdala reflexes drive engagement in the situation. Engagement mitigates and resolves the crisis. Engagement also modulates the stress responses, fear reactions, and amygdala reflexes that enable that engagement. Counterintuitively, stress-impaired cognition, fear-circuit behaviors, and amygdala-driven reflexive behaviors caused by the crisis are necessary for engagement in that crisis.
Introduction
Paramedics brought a pediatric motor vehicle collision victim into the trauma room. Staff became involved with the patient’s care. The chief surgical resident for trauma entered, immediately calling out orders. Any miss brought a stiff rebuke from the chief resident. As the pediatric resident entered, the surgical resident demanded orders for specific drugs. The pediatric resident looked through a book and began calculating drug dosages. The surgical resident demanded a faster response. Everyone in the room worked rapidly, directing their attention toward the child rather than each other.
Later, the surgical resident ridiculed the pediatric resident for searching for drug doses in a book and using a calculator. The trauma residents were proud of their performance. What they saw was constant activity in response to their orders. One of the authors (DvS) had witnessed his first extensive resuscitation in a hospital and had a different view. The author observed the resuscitation team operating under the influence of fear.
The surgical resident did most of the talking, the tone tense, becoming louder as the resuscitation progressed. Communication only occurred from the chief resident to an individual. If people communicated at all, it was through eye contact and whispers. Coordination was about not interfering with each other rather than working together. Information was only given to the surgical resident when requested and only for that specific request. Nothing was volunteered. All actions followed direct orders from the resident; there was little independent action to fix an immediate problem.
[CLICK TO READ FULL ARTICLE BELOW REFERENCES]
Conclusion
The characteristics of forcing functions and abrupt crises create our ability to engage those crises.
Stress-induced cognitive impairments “disarm” the executive functions to prevent intrusion of abstractions and future thinking while limiting various memory systems. Stress brings mental focus to the immediate circumstances.
Fear circuitry behaviors, operating below the level of consciousness, keep us safe from threat. We can operate with safety. Distance can reduce stress, returning some of our cognitive functions.
The amygdala operates at the subcortical level, identifying threats and initiating survival behaviors before we can recognize danger.
Without modulation, stress-induced cognitions become disorders, fear circuitry behaviors become disruptive, and amygdala-driven fear behaviors become dangerous. Inadequate top-down modulation from executives, administrators, regulators, and legal counsel contributes to the ecology of fear. Repeated references to risk extend the span of control for this leadership. Such extended control, however, impairs engagement in the crises that the leaders hope to mitigate. However, not only is engagement impaired at the level of local groupings but also impaired is the necessary close-in support from the full field view. Over time, there will be a widening of the operational gap between the central organizational authority and the operational line authority.
These cognitions and behaviors can become normalized through bottom-up incorporation into the organization’s culture. Because they are natural and produce swift results, they appear effective. This normalization creates unrecognized stress responses, unrecognized fear reactions, and situational cognitive distortions. The result is impaired immediate engagement of early heralds of failure and covert, compensated system failure.
Recognition of the inherent vices of stress and threat can move individuals and organizations toward effective modulation. Gaining the ability to operate in uncertainty and time compression permits the use of greater resources, widening the spectrum of available information. A great limitation to problem-solving is our mental limits on ourselves and each other. Seeing the problem as a puzzle rather than as mysteries to investigate is simpler. Stress and fear impede the engagement of mysteries. We can use Adrian Wolfberg’s concept of Full Spectrum Analysis (77) when unimpeded. We can then extend Neonatology into new areas and the mystery of the next infant’s illness.
References:
1. Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology. 1908;18:459-82.
2. Bracha HS. Human brain evolution and the “Neuroevolutionary Time-depth Principle:” Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2006;30(5):827-53.
3. van Stralen D, McKay SD, Hart CA, Mercer TA. Implementation of High-Reliability Organizing (HRO): The Inherent Vice Characteristics of Stress, Fear, and Threat. Neonatology Today. 2022;17(6):26-38.
4. van Stralen D, McKay SD, Hart CA, Mercer TA. High Reliability Organizing (HRO) for the Color of Noise: Forcing Functions, Collaboration, and Safety. 17. 2022;4:19-30.
5. van Stralen D, McKay SD, Mercer TA. Disaster Series: High Reliability Organizing (HRO) as Self-Organization. 2022;17(2):14-27.
6. van Stralen D, McKay SD, Mercer TA. Operational Logics and Inference During [1/f or f -1] Noise Events: High-Reliability Operations (HRO). Neonatology Today. 2022;17(3):18-31.
7. van Stralen D, Mercer TA. Inductive Processes, Heuristics, and Biases Modulated by High-Reliability Organizing (HRO) for COVID-19 and Disasters. Neonatology Today. 2021;16(9):104-12. doi: 10.51362/neonatology.today/20219169104112.
8. van Stralen D, McKay SD, Mercer TA. Disaster Series: The Abrupt NICU Evacuation – Disasters without a Plan. Neonatology Today. 2021;16(12):10-22.
9. van Stralen D, McKay SD, Mercer TA. Disaster Series: The Use of Information for Wildland Fire and the NICU: Combined Evacuation and Sheltering. Neonatology Today. 2021;16(11):105-14.
10. van Stralen D, McKay SD, Mercer TA. Disaster Series: Prolonged Improvisation – High Reliability Organizing, the NICU, and Hurricanes. Neonatology Today. 2022;17(1):10- 27.
11. van Stralen D, McKay SD, Mercer TA. High-Reliability Organizing (HRO) for Disasters: Capability and Engagement. Neonatology Today. 2022;17(10):18-32.
12. van Stralen D, Mercer TA. High-Reliability Organizing (HRO) in the COVID-19 Liminal Zone: Characteristics of Workers and Local Leaders. Neonatology Today. 2021;16(4):90-101. doi: 10.51362/neonatology.today/2021416490101.
13. van stralen D, McKay SD, Stralen Ev, Mercer TA. Disaster Series: The Function of Engagement for High Reliability Organizing (HRO). Neonatology Today. 2022;17(12):16-28.
14. van Stralen D, McKay SD, Hart CA, Mercer TA. Implementation of High Reliability Organizing (HRO): The Inherent Vice of Stress, Fear, and Threat. Neonatology Today. 2022;17(5):24- 35.
15. van Stralen D, Mercer TA. Pragmatic High-Reliability Organizations (HRO) Modulates the Functions of Stress and Fear Behaviors During Pandemic COVID-19: The Stress- Fear-Threat Cascade. Neonatology Today. 2020;15(10):126- 34. doi: 10.51362/neonatology.today/2020101510126134.
16. van Stralen D, McKay SD, Mercer TA. Engagement in High Reliability Organizing (HRO): The Individual Matters. Neonatology Today. 2023;18(2):30-45.
17. van Stralen D, Byrum S, Inozu B. High Reliability for a Highly Unreliable World: Preparing for Code Blue through Daily Operations in Healthcare. North Charleston, SC: CreatSpace Publishing; 2017.
18. van Stralen D, Mercer TA. High Reliability Organizing (HRO) is the Extension of Neonatology during Pandemic COVID-19. Neonatology Today. 2021;16(5):97-109. doi: 10.51362/neonatology.today/2021516597109.
19. van Stralen D, McKay SD, Mercer TA. Disaster Series: High Reliability Organizing for (HRO) Disasters–Disaster Ecology and the Color of Noise. Neonatology Today. 2021;16(12):96- 109. https://doi.org/10.51362/neonatology.today/2021161296108.
20. Price JF. Lagrangian and eulerian representations of fluid flow: Kinematics and the equations of motion: MIT OpenCourseWare; 2006.
21. James W. Essays in radical empiricism. Oxford, UK: Oxford Text Archive Core Collection; 1912.
22. Gaukroger S. Descartes: An intellectual biography. Oxford, UK: Clarendon Press; 1995.
23. Dewey J. Experience and Nature. New York, NY: Dover Publications, Inc; 1958.
24. van Stralen D, McKay S, Williams GT, Mercer TA. Tactical Improvisation: After-Action/ Comprehensive Analysis of the Active Shooter Incident Response by the San Bernardino City Fire Department December 2, 2015. San Bernardino, CA: San Bernardino County Fire Protection District; 2017.
25. Ivanov PC, Amaral LN, Goldberger AL, Stanley HE. Stochastic feedback and the regulation of biological rhythms. EPL (Europhysics Letters). 1998;43(4):363.
26. Kaitala V, Ylikarjula J, Ranta E, Lundberg P. Population dynamics and the colour of environmental noise. Proceedings of the Royal Society of London Series B: Biological Sciences. 1997;264(1384):943-8.
27. Ivanov P, Ma QD, Bartsch RP, Hausdorff JM, Nunes Amaral LA, Schulte-Frohlinde V, et al. Levels of complexity in scale-invariant neural signals. Phys Rev E Stat Nonlin Soft Matter Phys. 2009;79(4 Pt 1):041920. Epub 2009/06/13. doi: 10.1103/PhysRevE.79.041920. PubMed PMID: 19518269; PubMed Central PMCID: PMCPMC6653582.
28. van Stralen D, Mercer TA. During Pandemic COVID-19, the High-Reliability Organization (HRO) Identifies Maladaptive Stress Behaviors: The Stress-Fear-Threat Cascade. Neonatology Today. 2020;15(11):113-24. doi: 10.51362/neonatology.today/2020111511113124.
29. Boyd J. The Strategic Game of ? and ? In: Hammond GT, editor. A discourse on winning and losing. Maxwell AFB, Alabama: Air University Press; 2018. p. 255-314.
30. Novaco RW. The cognitive regulation of anger and stress. In: Kendall PC, Hollon SD, editors. Cognitive-behavioral interventions: Theory, research, and procedures. New York, New York: Academic Press; 1979. p. 241-85.
31. Shields GS, Sazma MA, Yonelinas AP. The effects of acute stress on core executive functions: A meta-analysis and comparison with cortisol. Neuroscience & Biobehavioral Reviews. 2016;68:651-68.
32. Rodrigues SM, LeDoux JE, Sapolsky RM. The influence of stress hormones on fear circuitry. Annual Review of Neuroscience. 2009;32:289-313.
33. Arnsten AF. Stress signalling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci. 2009;10(6):410-22. Epub 2009/05/21. doi: 10.1038/nrn2648. PubMed PMID: 19455173; PubMed Central PMCID: PMCPMC2907136.
34. Hediger H. Wild animals in captivity. London, UK: Butterworths Scientific Publications; 1950.
35. LeDoux JE, Pine DS. Using Neuroscience to Help Understand Fear and Anxiety: A Two-System Framework. Am J Psychiatry. 2016;173(11):1083-93. Epub 2016/11/02. doi: 10.1176/appi.ajp.2016.16030353. PubMed PMID: 27609244.
36. van Stralen D, Mercer TA. During Pandemic COVID-19, the High-Reliability Organizations (HRO) Identifies Maladaptive stress Behaviors: The Stress-Fear-Threat Cascade. Neonatology Today. 2020;15(11):113-23.
37. Fellows LK, Farah MJ. The role of ventromedial prefrontal cortex in decision making: judgment under uncertainty or judgment per se? Cereb Cortex. 2007;17(11):2669-74. Epub 2007/01/30. doi: 10.1093/cercor/bhl176. PubMed PMID: 17259643.
38. Quintana J, Fuster JM. From perception to action: temporal integrative functions of prefrontal and parietal neurons. Cerebral Cortex. 1999;9(3):213-21.
39. Fuster JnM. Prefrontal neurons in networks of executive memory. Brain research bulletin. 2000;52(5):331-6.
40. Fuster JnM. Synopsis of function and dysfunction of the frontal lobe. Acta Psychiatrica Scandinavica. 1999;99:51-7.
41. LeDoux JE. Emotion circuits in the brain. Annual review of neuroscience. 2000;23(1):155-84.
42. Joëls M, Fernandez G, Roozendaal B. Stress and emotional memory: a matter of timing. Trends in cognitive sciences. 2011;15(6):280-8.
43. Shtulman A, Valcarcel J. Scientific knowledge suppresses but does not supplant earlier intuitions. Cognition. 2012;124(2):209-15.
44. Lupien SJ, Lepage M. Stress, memory, and the hippocampus: can’t live with it, can’t live without it. Behavioural Brain Research. 2001;127(1-2):137-58.
45. Kozlowska K, Walker P, McLean L, Carrive P. Fear and the Defense Cascade: Clinical Implications and Management. Harv Rev Psychiatry. 2015;23(4):263-87. Epub 2015/06/11. doi: 10.1097/HRP.0000000000000065. PubMed PMID: 26062169; PubMed Central PMCID: PMCPMC4495877.
46. Wikenheiser AM, Redish AD. Decoding the cognitive map: ensemble hippocampal sequences and decision making. Current Opinion in Neurobiology. 2015;32:8-15.
47. Lisman J, Buzsáki G, Eichenbaum H, Nadel L, Ranganath C, Redish AD. Viewpoints: how the hippocampus contributes to memory, navigation and cognition. Nature neuroscience. 2017;20(11):1434-47.
48. Schauer M, Elbert T. Dissociation Following Traumatic Stress: Etiology and Treatment. Zeitschrift für Psychologie/ Journal of Psychology. 2010;218(2):109-27.
49. Allen JG, Console DA, Lewis L. Dissociative detachment and memory impairment: Reversible amnesia or encoding failure? Comprehensive Psychiatry. 1999;40(2):160-71.
50. Murty VP, Maureen Ritchey, Adcock RA, LaBar KS. fMRI studies of successful emotional memory encoding: A quantitative meta-analysis. Neuropsychologia. 2010;48(12):3459-69.
51. van Stralen D, Westmoreland T. Use of a visual five-point respiratory exam to evaluate breathing in the operational area. Special Operations Medical Association Scientific Assembly (SOMSA); December 8-11, 2014; Tampa, FL2014.
52. McConnell M, van Stralen D. Emergency medical decision-making in the tactical environment. The Tactical Edge (National Tactical Officers Association). 1997;15(3):32-9.
53. Brill-Maoz N, Maroun M. Extinction of fear is facilitated by social presence: Synergism with prefrontal oxytocin. Psychoneuroendocrinology. 2016;66:75-81. Epub 2016/01/23. doi: 10.1016/j.psyneuen.2016.01.003. PubMed PMID: 26799850.
54. Lloyd DM. The space between us: A neurophilosophical framework for the investigation of human interpersonal space. Neuroscience & Biobehavioral Reviews 2009;33(3):297- 304.
55. Graziano MS, Cooke DF. Parieto-frontal interactions, personal space, and defensive behavior. Neuropsychologia. 2006;44(6):845-59. Epub 2005/11/10. doi: 10.1016/j.neuropsychologia.2005.09.009. PubMed PMID: 16277998.
56. Oatley K, Johnson-Laird PN. Cognitive approaches to emotions. Trends Cogn Sci. 2014;18(3):134-40. Epub 2014/01/07. doi: 10.1016/j.tics.2013.12.004. PubMed PMID: 24389368.
57. Mobbs D, Petrovic P, Marchant JL, Hassabis D, Weiskopf N, Seymour B, et al. When fear is near: threat imminence elicits prefrontal-periaqueductal gray shifts in humans. Science. 2007;317(5841):1079-83. Epub 2007/08/25. doi: 10.1126/science.1144298. PubMed PMID: 17717184; PubMed Central PMCID: PMCPMC2648508.
58. Adolphs R. The biology of fear. Curr Biol. 2013;23(2):R79- 93. Epub 2013/01/26. doi: 10.1016/j.cub.2012.11.055. PubMed PMID: 23347946; PubMed Central PMCID: PMCPMC3595162.
59. Koutsikou S, Apps R, Lumb BM. Top down control of spinal sensorimotor circuits essential for survival. The Journal of Physiology. 2017;595(13):4151-8.
60. Watson TC, Koutsikou S, Cerminara NL, Flavell CR, Crook J, Lumb BM, et al. The olivo-cerebellar system and its relationship to survival circuits. Frontiers in Neural Circuits. 2013;7.
61. LeDoux JE. Coming to terms with fear. Proc Natl Acad Sci U S A. 2014;111(8):2871-8. Epub 2014/02/07. doi: 10.1073/pnas.1400335111. PubMed PMID: 24501122; PubMed Central PMCID: PMCPMC3939902.
62. Abrams MP, Carleton RN, Steven Taylor, Asmundson GJ. Human tonic immobility: Measurement and correlates. Depression and Anxiety 2009;26(6):550-6.
63. Cannon TD, Keller MC. Endophenotypes in the genetic analyses of mental disorders. Annual Review of Clinical Psychology. 2006;2(267-290). doi: 10.1146/annurev.clinpsy.2.022305.095232.
64. Iacono WG. Endophenotypes in psychiatric disease: prospects and challenges. Genome Medicine. 2018;10:1-3. doi: 10.1186/s13073-018-0526-5.
65. Morse JL, Wooldridge JS, Afari N, Angkaw AC, Schnurr PP, Lang AJ, et al. Associations among meaning in life, coping, and distress in trauma-exposed US military veterans. Psychological Services. 2023. doi: https://doi.org/10.1037/ser0000755.
66. Dixon DP, Weeks M, Boland R, Perelli S. Making Sense When It Matters Most: An Exploratory Study of Leadership In Extremis. Journal of Leadership & Organizational Studies. 2016;24(3):294-317. doi: 10.1177/1548051816679356.
67. Grant AM. Leading with Meaning: Beneficiary Contact, Prosocial Impact, and the Performance Effects of Transformational Leadership. Academy of Management Journal. 2012;55(2):458-76. doi: 10.5465/amj.2010.0588.
68. Hannah ST, Uhl-Bien M, Avolio B, Cavarretta FL. A framework for examining leadership in extreme contexts. The Leadership Quarterly. 2009;20:897-919. doi: 10.1016/j.leaqua.2009.09.006.
69. Brown JS, Laundre JW, Gurung M. The Ecology of Fear: Optimal Foraging, Game Theory, and Trophic Interactions. Journal of Mammalogy. 1999;80(2):385-99.
70. Creel S. The control of risk hypothesis: Reactive vs. proactive antipredator responses and stress‐mediated vs. food‐mediated costs of response. Ecology Letters 2018;21(7):947-56.
71. Laundré JW, Hernández L, Altendorf KB. Wolves, elk, and bison: reestablishing the “landscape of fear” in Yellowstone National Park, USA. Canadian Journal of Zoology. 2001;79(8):1401-9.
72. Laundré JW, Hernández L, Ripple WJ. The landscape of fear: ecological implications of being afraid. The Open Ecology Journal 2010;3(1):1-7.
73. van Stralen D, Gambino W. Error as a Faulty Failure Signal. Neonatology Today. 2020;15(8):114-7.
74. Weick KE. Enactment and Organizing. The Social Psychology of Organizing. Second ed. New York, NY: McGraw-Hill, Inc.; 1979. p. 147-69.
75. van Stralen D, Gambino W. Error as a Faulty Failure Signal. Neonatology Today. 2020;15(9):114-7. doi: 10.51362/neonatology.today/20209159114117.
76. Bowker GC, Star SL. Invisible Mediators of Action: Classification and the Ubiquity of Standards. Mind, Culture, and Activity. 2000;7(1-2):147-63. https://doi.org/10.1080/10749039.2000.9677652.
Disclosures: No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.