Zachary Kermitz:  Well, hey everybody, my name is Zach. I'm one of the flight nurses that you probably hear coming and going over the hospital fairly regularly, up there with AirCare. And Roberta asked me to come on to give a version of a talk I gave at the San Juan Trauma and Critical Care Conference. And that was about a topic that we call metacognition, meaning thinking about thinking. And when I gave that presentation, I really gave it in the context of medical care, and what we do on the ambulance, and in the ICU, and with AirCare. But the ideas that I talked about in that presentation are pretty broadly applicable to what we all do at the hospital, really.

And the way I decided to address the topic of metacognition, and thinking about our thinking, and how that improves our care was through these two paradoxical statements that have always kind of stuck with me throughout my career. They're not ideas that are my own. I didn't come up with either of these. But they've really made an impact on what I do and have really helped get me to where I am today. And they guide what I do on each and every shift. And because they're paradoxes, they don't make sense at first. They seem contradictory when you hear them. But when you stop and break them down, I found them to provide quite a bit of wisdom that's really been helpful for me.

And the first of these is the statement that discipline equals freedom. This paradox of wisdom comes from a guy named Jocko Willink. He's a retired Navy SEAL and author. Not my idea, not my statement that I came up with, just borrowed it from him. And discipline equals freedom, when you break it down, really gets to the notion that if we build good habits by being consistent and disciplined about it, we avoid becoming complacent with what we end up doing at work.

Just applying it more broadly to everyone at the hospital, there's some things that I do that we could all find ourselves doing that I've found to be beneficial, things like I always make sure I get in at least ten minutes early to my shift. That way, I've got a drop on whatever's coming. If there's flights waiting for us, I already know about it, I've got time to get changed, put my food away. But that same notion of just make sure you get in a couple minutes early really applies to all of us and almost anything that we do in our own lives, even outside of work.

So for example, you're going to the airport, make sure you get there a little earlier, probably than you even might think you need to. How's the parking situation going to be? If you've got to make it to your kid's recital or their game that they have, you can get good seats that way. And in the same notion, when we're all showing up to work, who knows what's going to be waiting in your inbox when you open it up for the first time that morning. And if you've got just a little bit of extra time to get yourself settled, you can just be a little bit more prepared to tackle those things and get a drop on them.

And speaking of things that I apply it to that we all really have to do in the course of our work is I'm really good at making sure, for example, that I always log out of my computer when I walk away from it. Just that quick logout could help prevent us from ending up with another payroll fiasco like we all had once upon a time. Quick thing, easy to do, but it could save us a lot of hassle down the road.

And this notion of discipline equals freedom is particularly important for things that really rarely go wrong, but when they do, they can have really catastrophic results. And it's an acknowledgement of your own humility. And saying that no matter how many times you've done something or no matter how good you are at it, even if you're the person in your department that people come to to fix a problem or to take care of a task, it's you acknowledging that, "You know what? I could still get it wrong. Something completely unexpected could happen that doesn't typically happen in the course of doing this. And then, what am I going to do? Am I going to be prepared to respond and react to that in such a way that we're able to recover?" It might be something that happens in an unanticipated manner, you know, equipment that you usually use to complete that task breaks or something like that. But if you have the discipline to fully understand every aspect of what that task is, you'll be able to just breeze right through it, even when things really go sideways. And when you're fully prepared to that extent, when you've had the discipline to build up those good habits of going through the full steps something, even maybe if they're a little cumbersome, you've really optimized your ability to focus on the task at hand. And you don't have to worry about, "Well, what if this happens? What if that happens?" You already know, and you have a plan in place to tackle it. And so, that way, you've just got a lot more, I like the term cognitive bandwidth. You've got a lot more computing power available in your brain to tackle things when they do happen.

And the other statement that I talked about in my presentation is the idea that slow is smooth, smooth is fast. And I've heard that restated actually from a British transplant surgeon. He rephrased it as less haste means more speed, for example. And this notion that slow is smooth, smooth is fast might seem to be really paradoxical coming from someone at AirCare, where the whole idea of the airplane and the helicopter is speed. If a patient needs to get to a pediatric brain surgeon down in Albuquerque, the whole idea is that we can get them there in 45 minutes to an hour versus that three-hour drive.

So, how does slow is smooth, smooth is fast apply to what we do? Well, what it really means is that by being intentional and deliberate in going through the steps of your work, you're less likely to have something go wrong, even if it's something you've done a million times. Because we all know we have that time you flub something, just a little brain fart and you mess something up, or a piece of equipment breaks or is missing. Well then, you're not going to end up with those delays that ultimately are going to slow you down if you just were systematic and slow about doing it from the beginning. And all those little delays that can frequently happen when you are rushing, or you are trying to be fast, just for the sake of speed, those little hiccups that you run into, they add up. And in the long run, they cause delays that ultimately cause trouble for you. And if this is a particularly stressful situation, like what a lot of us deal with, then it only compounds the likelihood that you're going to have an error happen in your process.

And more broadly speaking, even outside of critical care context, all of our memories are fairly limited in their short-term capacity. I know mine is. We can only hold on to like six, maybe eight little pieces of information simultaneously. And so, when you're in a stressful situation or you're trying to do something that you don't have to do all that often, don't try to juggle all of those at once, and go slow. And then, you're less likely to forget some little component of whatever it is that you're doing.

Speed in my job is pretty important at the end of the day, like we talked about. If I don't take those few extra seconds to make sure that the stretcher is properly secured in the helicopter or in the airplane, it could end up having really catastrophic consequences in the long run for that particular patient. Even though in the moment it seems like it takes a little bit of extra time that almost feels unnecessary just to make sure that everything is in its place and everything is secured and belted and locked down. But if we know where all the equipment is each and every time, it's in the same place, and we know that everything is locked in and it might not pop loose if we hit some turbulence on the way, it's going to avoid causing trouble that's going to slow us down really in the long run.

So, those are just those two little paradoxes that have really helped me get to the point that I'm at in my career, and that guide the care that I provide every day. But I also have found them to be just as applicable in the small things that we do at work, coming and going, making sure you clock in and out, those kind of things, and more broadly in life. And they've really kind of helped me remove a lot of the stress and worry that comes along with a lot of these processes and things that you got to do and get done. And they just help me be a little bit more relaxed. But that's pretty much it. I'm an open book, if you ever see me in the hall, I'm the big tall guy with the mohawk, never hesitate to ask or talk to me about it. Have a great day, everybody.