van Stralen/Neuropsychology

Brain-based response to uncertainty

van Stralen began his experience with decision making under pressure while he was a high school student when he witnessed, with peripheral participation, a rescue for a dying mountain climber. This followed work as an ambulance driver, fire department rescue ambulance, and paramedic training in the 1970s where his mentors were combat veterans from WWII, Korea, and Viet Nam and had experience with major fires, crimes, and riots. Significant was his training and experience with his Fire Station Commander, Bill Corr, who taught him the principles he would use throughout his medical career. His training, then, came from an amalgamation of military combat, law enforcement, firefighting, ambulance, early emergency medicine, and winter mountaineering. His early career was in the field when one must deal with situations before it is known as an accident and where lives change over seconds with uncertain futures. 

With this background he attended medical school and witnessed his first trauma resuscitation in the trauma center. Had the actions he witnessed occurred in a field emergency the participants, at best, would have been terminated from their position. This experience, along with others early in his career, led to his quest to understand the science that made his early mentors right and what made the health care professionals believe they were right.

High Reliability is in the details, but appropriate details, and it is the individual who perceives the need for action and then choose to act. The individual then takes this to others by identification, interpretation, and translation so others may understand the circumstances. What has happened is the Indeterminate Problem of threat, uncertainty to what will work, and time-dependence. Left to the fear response, the brain’s amygdala drives perception to action without the intervention of thought. The past experience of humbling vulnerability, such as from the sensation of intense failure or the experience of near death, instead drives the individual to collaboration with others, even seeking out and identifying supportive others. This collaboration is to create a team by shared objective and collaborative enactment toward the common goal. Information is sparse but rich – objective, articulate, and succinct.

The individual functions through neuroanatomy, reasoning, and attitudes. The prefrontal cortex, producing the brain’s Executive Functions, makes binary decisions (right/wrong), abstract thought including the future, and planning. Here, perception goes to thought goes to action. The amygdala, a more primitive region sometimes called the reptilian brain, is the survival brain where perception goes to action without thought. This is where fight-flight-freeze reside. But the High Reliability person works in the cingulate cortex where the amygdala is modulated, error is identified, and adaptive decisions are made to find what works.

The High Reliability individual uses inductive reasoning, increasing the strength of evidence to increase the strength of the conclusion. As these strengths vary, evidence is added or dropped and conclusions change in an active dynamic during engagement. Deductive reasoning, where facts (100% known) guarantee the hypothesis, is a luxury not available to the individual until long after events resolve and data can be evaluated.

Attitudes, as preformed favor or disfavor, guide behaviors. This is the richness of High Reliability as we discuss attitudes toward failure, complexity, honesty, duty, empathy and so on. This is where the individual learns to think and behave in a High Reliability manner and where knowledge is shared.

*Courtesy of Patty Sokol

Bill Corr, Obituary. We have witnessed the passing of another legend who served with honor and distinction as a loving husband, father, professional firefighter and union leader. Jim Perry, Editor November/December 2005 Los Angeles Firefighter