On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace
Written by a retired US army colonel with a PhD in psychology, On Combat describes the psychological and physiological effects combat has on the human condition. Although aimed at those facing physical violence and conflict—namely soldiers and law enforcement officers—there are uncanny comparisons to be made with pre-hospital critical care. By replacing ‘combat’ with ‘resuscitation’, certain sections speak clearly to the paramedic profession.
One of the most relevant sections was on fear, physiological arousal and performance. Four conditions are used to describe the various changes in performance factors under increasing levels of stress: white (stress free) to yellow (vigilant), red (optimal survival) and finally black (overload). At a heart rate of around 115 bpm, fine motor skills begin to deteriorate. Conditions red and black bring about a reduction in complex motor skills, cognitive functioning, and auditory and visual senses. This is also applicable to the states we find patients involved in stressful events such as traffic collisions or violence. The associated increases in vital signs are well documented, but their inability to recall events is not so widely known.
The text would also benefit those with an interest in pre-hospital training and education. Simulation, stress inoculation and learning motor-skills in high-pressured situations are discussed in some depth. Certain myths are dispelled, for instance in moments of crisis we don't rise to the occasion, we sink to our level of training. Grossman also discusses in some depth the science and psychology behind debriefs, mitigating PTSD, and techniques to control that rising panic.
The text is very well structured and wonderfully lucid. The points are well illustrated with liberal use of real-life examples. Though the style is a touch inconsistent, wavering between an Americanised ode to ‘warriors’ and a serious academic work, this is quickly forgotten given its strength lies in the quality of substance.
What On Combat offers is a highly salient text that sheds light on the neglected human factors of pre-hospital care. Mandatory reading for anyone seeking to improve or understand their practice.