November 15, 2025 • 14 mins
In this episode of the GSAC EP podcast, Dr. Amy Hildreth, Assistant Professor of Military and Emergency Medicine, shares her insights and personal experiences on navigating uncertainty in military medicine. From her first deployment to Kandahar to managing mass casualty events, Dr. Hildreth discusses the critical importance of developing uncertainty tolerance, managing stress, and using practical frameworks to enhance performance in high-stakes environments. The episode explores strategies such as preparation, cognitive flexibility, mentorship, simulation training, and mindfulness to help medical professionals and trainees thrive amid the unknown. Listeners will gain valuable tools for embracing uncertainty and leading with confidence on and off the battlefield.
#MilitaryMedicine #EmergencyMedicine #UncertaintyTolerance #StressManagement #Mentorship #SimulationTraining #MedicalEducation #MedicalPodcast #VeteransCare #ProlongedCasualtyCare
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Amy Hildreth (00:00):
Announcer,
Narrator (00:07):
welcome to the government services Chapter of
the American College ofEmergency Physicians. Podcast
gsapp represents emergencyphysicians who work in the
federal government, includingactive duty military National
Guard and military reserves, aswell as the Veterans
Administration, Indian HealthService and other federal
agencies,our mission is advancing
(00:29):
emergency care for America'sheroes. In this podcast, we
bring you lectures andconversations with leaders in
federal emergency medicine tohelp you better care for your
patients and lead yourdepartments. The views expressed
on this podcast are personalviews and do not represent the
views of the Department ofDefense, any branch of the
(00:49):
military or the federalgovernment, and they do not
constitute endorsement of anyproduct by any of these
entities. The
Matthew Turner (01:17):
Hi, good morning. This is Captain Matthew
Turner with another GSA sitpodcast. In this episode, we
have Dr Amy Hildreth, AssistantProfessor of military and
emergency medicine at USUS, hereto discuss managing uncertainty
in military medicine.
Amy Hildreth (01:33):
Hi everyone. Good afternoon. I am Amy Hildreth. I
am an ER doctor. I work withColonel Shen at USU. I wanted to
talk to you guys today aboutuncertainty and uncertainty
tolerance, because as I am newstaff at USU, I'm trying to
figure out what useful thingsthat we can teach to help our
(01:57):
students manage the wars of thefuture. We've had a lot of talks
today about how we think thingsare going to happen, what we
think we need to be preparedfor.
But the truth is, we reallydon't know, as with everyone, I
don't have any fun disclaimersor financial things to disclose.
(02:20):
So hopefully, over the next 14minutes, we can talk about
uncertainty and uncertaintytolerance, talk about how
specifically this applies in themilitary setting, and review
strategies to reduce uncertaintyand build that tolerance. When I
(02:41):
deployed for the first time. SoI went to civilian medical
school, civilian residency. Ihad been at San Diego for about
nine months, and got sent toKandahar, to the role three
there with no experience. Myfirst trauma was about 36 hours
(03:03):
after we arrived and took overthe hospital. We had a mass cow
with 12 patients. I had aelderly. It was an elderly, an
elderly service member, an olderservice member who was shot in
the neck, spitting out bloodfrom his mouth, gray and ashen,
(03:25):
sitting up, clutching his neck,staring at me. I, from a medical
standpoint, wasn't sure exactlyhow to manage that all by
myself, without the TraumaCenter at my back. How was? How
was? What was the best way toapproach that intubation and to
handle that medically. From asecurity standpoint, my corpsman
is telling me that they actuallydidn't set up the intake
(03:48):
appropriately, and none of thepatients were appropriately
searched prior to bringing theminto the trauma bay. So we were
trying to also search and manageany security threats from all of
these patients who had just comeinto the role three without
being appropriately managed. Wewent river city for the first
time, which I didn't know whatthat meant, that they shut off
(04:12):
all communication and Internet,and I couldn't communicate with
my family and tell my son that Iwas okay, and I had no idea how
we were going to evac thepatient. What was going to
happen next? How long I had totake care of this incredible
injury, as well as the 17 otherpatients that were there with
me? Obviously, it wasn't all bymyself, and we got through it,
(04:34):
but that uncertainty on all ofthose levels was really just
compounding and overwhelming.
And I think there's so many ofyou in this room that have had
to manage similar situations,and I just think that had I had
been more prepared for that, Imaybe could have done a better
job, and I hope that I can helpsend more people forward. Being
(04:58):
more prepared for what mighthappen. Dr natat showed this
slide. So this graph earlier,I'm sure we've all seen it. That
there's a certain level ofstress that increases
performance, but once you getpushed too far, you stop being
able to perform maximally. Thisleads to anxiety, indecision,
(05:19):
errors, you just are not able tofunction at your best. The more
you can decrease your stress,reduce your uncertainty, and
know that you're able to managethe situation, the more that
you're going to be able to pushyourself back into that peak
performance in we just went overthis with my scenario. But in
(05:44):
uncertainty comes in all thesedifferent forms in military
medicine, whether it's themedical care itself, the
diagnosis, the treatment,whether it's the security and
are you safe? Is your team safe?
Or whether it's the ability tomanage your own performance in
(06:11):
future wars and lisco scenarios,we assume that we're going to
have to manage with prolongedcasualty care, from what we've
learned in Ukraine and ongoingwars and ongoing conflicts where
we don't have air superiority,we need to be able to manage
this, and we can't eliminate theuncertainty, but we need to
(06:36):
develop a tolerance for it. Thegoal is to be able to be
confident in knowing what to donext, knowing whether to act or
to wait, even if you're notconfident in your knowledge and
what's what you're aware of. Drhello and her colleagues came up
with this wonderful frameworkfor reducing and managing
(06:59):
uncertainty. So the idea is toreduce your uncertainty as much
as possible by recognizing it,classifying it, and increasing
your knowledge and thenevaluating and figuring out how
you can move forward with thedecision frameworks that you
have the biggest issue is theunknown unknowns, right? We can
(07:25):
go and try to plan for what weknow might happen, try to plan
for what we think might happen,but it's those things that we
don't even know we didn't knowthat always come back to really
bite you. So how do you preparefor that? And how can you be
aware? You have to be mindful ofyour assumptions and biases. You
(07:45):
have to look for signs thatyou're missing things. You have
to question your own judgment.
You have to ask for help. All ofthese things can help, but
again, you can never make it allgo away. You can classify your
uncertainty and put it indifferent buckets in order to
help you try to be able tomanage it better. Some of these
things that we talked aboutdiagnostic, resource evacuation,
(08:07):
uncertainty, thinking aboutdifferent perspectives. How can
I think about this differently?
How are other people thinkingabout this? I might have a lot
of experience from my civiliantrauma background. But what can
I learn from my corpsman who wasdeployed before? What can I
(08:27):
learn from the surgeon that I'mdeployed with? What is the
success look like for me? Whatis my co trying to accomplish?
What is leadership trying toaccomplish? What is the patient
trying to accomplish? All thesethings might help create a
better picture, acquiring asmuch knowledge as possible.
(08:48):
Hopefully, this is happeningbefore you get sent somewhere
where you have to manage this,but you can still acquire
knowledge in the situation.
While you're there, the patientwill tell you so many answers.
If you ask in prolonged casualtycare, one of the only things
that we have that is really abenefit is that prolonged time
(09:08):
with the casualty to continue toreassess, getting those vital
signs, getting those updates,using your ultrasound, as Dr
Apata showed us how to do, willhelp use all our available
resources. There are decisionmaking approaches that can help
us as well, utilizing yourheuristics and mental shortcuts,
(09:32):
utilizing the shared decisionmaking in your team that we
talked about, and going throughwith scenario planning. Fuzzy
Logic is using your kind ofdegrees of truth. There's
inherent ambiguity, so you'reusing that flexibility, the more
(09:52):
that we can harness ourcognitive flexibility and be
able to go. From the present athand to managing the acute blood
coming out of the neck wound, aswell as the big picture of, how
do I manage all of thesepatients in the department? How
do I manage my team? How do Imanage the long term goal,
(10:13):
planning the better off thatwill be? So how can we build a
toolkit to get better atmanaging uncertainty and to
increase our uncertaintytolerance. One of the best ways
to learn is to practice until weget all the mils partnerships
set up and everyone can go toPenn with Dr de Forest. Sim is
(10:36):
an excellent way to practice,especially in training, engaging
in reflection can also beincredibly useful. Mindfulness
techniques have been shown tohelp us manage stress in the
moment. The more that you canstop, take a deep breath, do
your own pulse, check and reduceyour internal stress, the better
(10:58):
you'll be able to manage thesescenarios in the moment, and
then thinking about that growthmindset and that cognitive
flexibility. So just the ideathat you can manage this, which
we all learn throughout ouremergency medicine training,
that idea of what is the nextand most necessary step that I
need to take, just as whenyou're driving in the dark with
(11:21):
your headlights and you can onlysee so far in front of your
face, as long as you can keepmaking those next decisions, you
can get to where you need to go.
Another excellent pathway isseeking incredible mentorship.
It's one of the amazing thingsabout conferences like GSA Sup,
(11:42):
where we all have time to gettogether and talk and learn and
share. So again, I can tell mystudents my experiences of what
I went through, but that's notgoing to be what their
experiences on their deploymentsin five or 10 years are going to
be. However, hopefully some ofthese frameworks and stories
(12:04):
will help us, just like Dr Mabrywas talking about, learning from
our history can really help usbetter, be prepared for the
future, going to our availableresources, our excellent
guidelines that we have,focusing on what we can control
and recognizing our limits incrisis, it's really important to
(12:27):
be okay with the acceptable andnot always striving for the best
possible outcome, because thatwill can short sight you and
keep you from being able tomanage everything appropriately.
That is all I have. I believe Ithought I had a thank you slide.
(12:51):
I'll take any questions.
Unknown (13:01):
Thanks. Amy, kind of a comment on on building your
uncertainty tolerance. I thinkanother thing for those of us
who work with medical studentsis having them realize, to be
honest with your uncertaintytolerance, especially when
you're mentoring people, whetheror not to go into emergency
medicine, and there arecertainly people that should not
be in the field that we're in,and just realistically can't be.
(13:23):
And obviously, in most in thiscrowd, it's it's too late for
us, but, but those medicalstudents who are considering
careers in emergency medicineinstead of just trying to
recruit people into our fieldthat we all love, I think
medical students need to behonest with themselves about
their uncertainty and and stresstolerance,
Amy Hildreth (13:40):
although I would challenge you, Captain Butler,
that we can grow our uncertaintytolerance, and there are ways to
improve it and so but youshould. We should all think
critically about what our ownuncertainty tolerance is and
whether emergency medicine isright for us. But if you are in
military medicine and you arenot comfortable with
(14:01):
uncertainty, you are probably inthe wrong place.
Unknown (14:07):
Great point, but certainly just responds All
right other questions from theaudience.
Amy Hildreth (14:14):
Thank you so much.
Thank you.
Narrator (14:22):
GSA, gsacep is proud to be the premier Continuing
Medical Education Source formilitary and federal emergency
physicians to purchase. CME forthe episode you just listened
to, please click on the link inthe show notes the government
services Chapter of the AmericanCollege of Emergency Physicians
promotes quality emergency careand enhances the development of
(14:44):
Emergency Physicians who serveour nation from training through
retirement. Learn more about ourchapter at WWW dot GSAC ep.org,
you.
Announcer,
Narrator (00:07):
welcome to the government services Chapter of
the American College ofEmergency Physicians. Podcast
gsapp represents emergencyphysicians who work in the
federal government, includingactive duty military National
Guard and military reserves, aswell as the Veterans
Administration, Indian HealthService and other federal
agencies,our mission is advancing
(00:29):
emergency care for America'sheroes. In this podcast, we
bring you lectures andconversations with leaders in
federal emergency medicine tohelp you better care for your
patients and lead yourdepartments. The views expressed
on this podcast are personalviews and do not represent the
views of the Department ofDefense, any branch of the
(00:49):
military or the federalgovernment, and they do not
constitute endorsement of anyproduct by any of these
entities. The
Matthew Turner (01:17):
Hi, good morning. This is Captain Matthew
Turner with another GSA sitpodcast. In this episode, we
have Dr Amy Hildreth, AssistantProfessor of military and
emergency medicine at USUS, hereto discuss managing uncertainty
in military medicine.
Amy Hildreth (01:33):
Hi everyone. Good afternoon. I am Amy Hildreth. I
am an ER doctor. I work withColonel Shen at USU. I wanted to
talk to you guys today aboutuncertainty and uncertainty
tolerance, because as I am newstaff at USU, I'm trying to
figure out what useful thingsthat we can teach to help our
(01:57):
students manage the wars of thefuture. We've had a lot of talks
today about how we think thingsare going to happen, what we
think we need to be preparedfor.
But the truth is, we reallydon't know, as with everyone, I
don't have any fun disclaimersor financial things to disclose.
(02:20):
So hopefully, over the next 14minutes, we can talk about
uncertainty and uncertaintytolerance, talk about how
specifically this applies in themilitary setting, and review
strategies to reduce uncertaintyand build that tolerance. When I
(02:41):
deployed for the first time. SoI went to civilian medical
school, civilian residency. Ihad been at San Diego for about
nine months, and got sent toKandahar, to the role three
there with no experience. Myfirst trauma was about 36 hours
(03:03):
after we arrived and took overthe hospital. We had a mass cow
with 12 patients. I had aelderly. It was an elderly, an
elderly service member, an olderservice member who was shot in
the neck, spitting out bloodfrom his mouth, gray and ashen,
(03:25):
sitting up, clutching his neck,staring at me. I, from a medical
standpoint, wasn't sure exactlyhow to manage that all by
myself, without the TraumaCenter at my back. How was? How
was? What was the best way toapproach that intubation and to
handle that medically. From asecurity standpoint, my corpsman
is telling me that they actuallydidn't set up the intake
(03:48):
appropriately, and none of thepatients were appropriately
searched prior to bringing theminto the trauma bay. So we were
trying to also search and manageany security threats from all of
these patients who had just comeinto the role three without
being appropriately managed. Wewent river city for the first
time, which I didn't know whatthat meant, that they shut off
(04:12):
all communication and Internet,and I couldn't communicate with
my family and tell my son that Iwas okay, and I had no idea how
we were going to evac thepatient. What was going to
happen next? How long I had totake care of this incredible
injury, as well as the 17 otherpatients that were there with
me? Obviously, it wasn't all bymyself, and we got through it,
(04:34):
but that uncertainty on all ofthose levels was really just
compounding and overwhelming.
And I think there's so many ofyou in this room that have had
to manage similar situations,and I just think that had I had
been more prepared for that, Imaybe could have done a better
job, and I hope that I can helpsend more people forward. Being
(04:58):
more prepared for what mighthappen. Dr natat showed this
slide. So this graph earlier,I'm sure we've all seen it. That
there's a certain level ofstress that increases
performance, but once you getpushed too far, you stop being
able to perform maximally. Thisleads to anxiety, indecision,
(05:19):
errors, you just are not able tofunction at your best. The more
you can decrease your stress,reduce your uncertainty, and
know that you're able to managethe situation, the more that
you're going to be able to pushyourself back into that peak
performance in we just went overthis with my scenario. But in
(05:44):
uncertainty comes in all thesedifferent forms in military
medicine, whether it's themedical care itself, the
diagnosis, the treatment,whether it's the security and
are you safe? Is your team safe?
Or whether it's the ability tomanage your own performance in
(06:11):
future wars and lisco scenarios,we assume that we're going to
have to manage with prolongedcasualty care, from what we've
learned in Ukraine and ongoingwars and ongoing conflicts where
we don't have air superiority,we need to be able to manage
this, and we can't eliminate theuncertainty, but we need to
(06:36):
develop a tolerance for it. Thegoal is to be able to be
confident in knowing what to donext, knowing whether to act or
to wait, even if you're notconfident in your knowledge and
what's what you're aware of. Drhello and her colleagues came up
with this wonderful frameworkfor reducing and managing
(06:59):
uncertainty. So the idea is toreduce your uncertainty as much
as possible by recognizing it,classifying it, and increasing
your knowledge and thenevaluating and figuring out how
you can move forward with thedecision frameworks that you
have the biggest issue is theunknown unknowns, right? We can
(07:25):
go and try to plan for what weknow might happen, try to plan
for what we think might happen,but it's those things that we
don't even know we didn't knowthat always come back to really
bite you. So how do you preparefor that? And how can you be
aware? You have to be mindful ofyour assumptions and biases. You
(07:45):
have to look for signs thatyou're missing things. You have
to question your own judgment.
You have to ask for help. All ofthese things can help, but
again, you can never make it allgo away. You can classify your
uncertainty and put it indifferent buckets in order to
help you try to be able tomanage it better. Some of these
things that we talked aboutdiagnostic, resource evacuation,
(08:07):
uncertainty, thinking aboutdifferent perspectives. How can
I think about this differently?
How are other people thinkingabout this? I might have a lot
of experience from my civiliantrauma background. But what can
I learn from my corpsman who wasdeployed before? What can I
(08:27):
learn from the surgeon that I'mdeployed with? What is the
success look like for me? Whatis my co trying to accomplish?
What is leadership trying toaccomplish? What is the patient
trying to accomplish? All thesethings might help create a
better picture, acquiring asmuch knowledge as possible.
(08:48):
Hopefully, this is happeningbefore you get sent somewhere
where you have to manage this,but you can still acquire
knowledge in the situation.
While you're there, the patientwill tell you so many answers.
If you ask in prolonged casualtycare, one of the only things
that we have that is really abenefit is that prolonged time
(09:08):
with the casualty to continue toreassess, getting those vital
signs, getting those updates,using your ultrasound, as Dr
Apata showed us how to do, willhelp use all our available
resources. There are decisionmaking approaches that can help
us as well, utilizing yourheuristics and mental shortcuts,
(09:32):
utilizing the shared decisionmaking in your team that we
talked about, and going throughwith scenario planning. Fuzzy
Logic is using your kind ofdegrees of truth. There's
inherent ambiguity, so you'reusing that flexibility, the more
(09:52):
that we can harness ourcognitive flexibility and be
able to go. From the present athand to managing the acute blood
coming out of the neck wound, aswell as the big picture of, how
do I manage all of thesepatients in the department? How
do I manage my team? How do Imanage the long term goal,
(10:13):
planning the better off thatwill be? So how can we build a
toolkit to get better atmanaging uncertainty and to
increase our uncertaintytolerance. One of the best ways
to learn is to practice until weget all the mils partnerships
set up and everyone can go toPenn with Dr de Forest. Sim is
(10:36):
an excellent way to practice,especially in training, engaging
in reflection can also beincredibly useful. Mindfulness
techniques have been shown tohelp us manage stress in the
moment. The more that you canstop, take a deep breath, do
your own pulse, check and reduceyour internal stress, the better
(10:58):
you'll be able to manage thesescenarios in the moment, and
then thinking about that growthmindset and that cognitive
flexibility. So just the ideathat you can manage this, which
we all learn throughout ouremergency medicine training,
that idea of what is the nextand most necessary step that I
need to take, just as whenyou're driving in the dark with
(11:21):
your headlights and you can onlysee so far in front of your
face, as long as you can keepmaking those next decisions, you
can get to where you need to go.
Another excellent pathway isseeking incredible mentorship.
It's one of the amazing thingsabout conferences like GSA Sup,
(11:42):
where we all have time to gettogether and talk and learn and
share. So again, I can tell mystudents my experiences of what
I went through, but that's notgoing to be what their
experiences on their deploymentsin five or 10 years are going to
be. However, hopefully some ofthese frameworks and stories
(12:04):
will help us, just like Dr Mabrywas talking about, learning from
our history can really help usbetter, be prepared for the
future, going to our availableresources, our excellent
guidelines that we have,focusing on what we can control
and recognizing our limits incrisis, it's really important to
(12:27):
be okay with the acceptable andnot always striving for the best
possible outcome, because thatwill can short sight you and
keep you from being able tomanage everything appropriately.
That is all I have. I believe Ithought I had a thank you slide.
(12:51):
I'll take any questions.
Unknown (13:01):
Thanks. Amy, kind of a comment on on building your
uncertainty tolerance. I thinkanother thing for those of us
who work with medical studentsis having them realize, to be
honest with your uncertaintytolerance, especially when
you're mentoring people, whetheror not to go into emergency
medicine, and there arecertainly people that should not
be in the field that we're in,and just realistically can't be.
(13:23):
And obviously, in most in thiscrowd, it's it's too late for
us, but, but those medicalstudents who are considering
careers in emergency medicineinstead of just trying to
recruit people into our fieldthat we all love, I think
medical students need to behonest with themselves about
their uncertainty and and stresstolerance,
Amy Hildreth (13:40):
although I would challenge you, Captain Butler,
that we can grow our uncertaintytolerance, and there are ways to
improve it and so but youshould. We should all think
critically about what our ownuncertainty tolerance is and
whether emergency medicine isright for us. But if you are in
military medicine and you arenot comfortable with
(14:01):
uncertainty, you are probably inthe wrong place.
Unknown (14:07):
Great point, but certainly just responds All
right other questions from theaudience.
Amy Hildreth (14:14):
Thank you so much.
Thank you.
Narrator (14:22):
GSA, gsacep is proud to be the premier Continuing
Medical Education Source formilitary and federal emergency
physicians to purchase. CME forthe episode you just listened
to, please click on the link inthe show notes the government
services Chapter of the AmericanCollege of Emergency Physicians
promotes quality emergency careand enhances the development of
(14:44):
Emergency Physicians who serveour nation from training through
retirement. Learn more about ourchapter at WWW dot GSAC ep.org,
you.
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