On Free Will, Consciousness, Attention & Gestalt

DasSMACC is just a few days away.  So to get you thinking I have decided to post this rambling train of thoughts that has been brewing for a while in the recesses of my brain.  In honour of our German hosts – this one is an exploration of the concept of Gestalt with a wide detour through evolutionary biology, neuroscience and beyond.  It is longish – but hey, you are all on flights with nothing better to do for a dozen hours!

Let us start with a simple game of “Rock, Paper, Scissors”.  OK, lets go, on three!   …1, 2, 3…

I went with “rock”.  Did you win, lose or draw?  It doesn’t really matter.

What I am interested in is this… how you came to be holding you hand in that configuration that you ‘chose’?  How did the apparent choice to select one of the three options manifest itself in your brain?  Was it a deliberate action?  Did you decide on 1, 2 or 3? Or was there that fleeting moment of vacillation just prior to the final shake… that moment where the choice seems to arise into your consciousness, merge through your motor cortex and shoot into your spinal cord?  Maybe you were not conscious of your choice at all.  Were you just as surprised as your competitor when you looked down and saw your second and third fingers extended to form a pair of scissors?

This simple children’s game demonstrates powerfully how our brains function.  We like to think that we are the author of our thoughts and subsequently our actions. We humans all share a sense of ‘free will’.  All of our experience from early life reinforces this continual, ’cause and effect’ world view.

However, there is that strange feeling in that moment – just before “3” where a decision is made, seemingly automatically.  We recognise this choice as our own.  It was generated in our mind somewhere, somehow and manifested in our action.  Yet, if pushed none of us can really explain how it came to pass.  So here is the question, consider this.  If I could place a probe on you skull that allowed me to see the neural activity in you mind and predict which object you will chose BEFORE you are aware of your own decision would you still have free will?

To put it another way – if you are truly unaware of your choice as it is forged in your subconscious mind, and have no way to control this choice – then do you actually have free will?  This may seem like science fiction, however these experiments have been conducted.  Neuroscientists have been testing this idea in experiments since the mid-80s.  Libet famously showed a “readiness potential” on the brain that preceded the conscious awareness of the intention to act by half a second of more.  These experiments have been repeated in various forms of the subsequent decades.  The basic model that seems to have emerged is that our brains construct a reality in which our conscious mind “observes” the passage of unconcscious intention into action.  We, that is our conscious minds, may not be the author / originators of our intentions or actions but more the witnesses to these as they materialise out of our minds.

Now this is a subtle point.  When I first read these ideas they clashed with my experience of my own internal world.  As I sit here writing these words, surely “I” am the author?  Could anyone else chose to write this ‘way’ or select these words and sentences?  If these ideas are arising in my unconscious mind and manifesting in keystrokes, does that make “me” a meagre passive observer as they break the surface of my consciousness?  If such a model were true, then how did this extraordinarily realistic internal world that I carry around in my skull come to exist?  How did my brain evolve such a duplicitous system?  If all the important stuff takes place at an unconscious level, why do I even need a conscious awareness?  In evolutionary terms, where is the pay-off for such an elaborate auto-hoax?  What do I need to have the illusion of free will to survive?  Well maybe it is all about peacock’s tails and sex.

Usually when we think about evolution, we consider natural selection.  “Nature red in tooth and claw”.  The constant struggle to survive, avoid predation and pass our genes onto the next generation.  However, there are other forms of selection that play their role alongside Darwin’s traditional system.  Consider the peacock’s tail.  It makes no sense at all from a pure survival analysis.  This elaborate, beautiful but ultimately unruly tail is an example of sexual selection.  Despite making life harder for its owner (the tail costs protein to grow, makes flight nearly impossible and would be an easy target for a hungry predator) it has evolved.  Why? Well that the longer, more vibrant tail results in more mates, more offspring and so the cycle continues.  The genes that code for a bigger tail survive, and are selected by the next generation… however these particular alleles are not the peacock’s – they reside within the peahen.  She is the one who makes the selection.  It is her genetically determined preference for long glossy, azure tail feathers that have lead to their production over the millennia.  So what does this have to do with free will? First a small detour for those not familiar with evolutionary biology.

We humans evolved over the past few million years as social primates.  We are scrawny, relatively weak but very bright primates.  The defining feature of human evolution is our utterly massive neocortex. Our brains are somewhat akin to the peacock’s tail. Large and expensive, beautiful and dazzling.  Evolution rarely “designs” [I know, it doesn’t] such elaborate machinery.  In Darwin’s game a pair of 3’s always beats an ‘Ace high’.  Our brain is more like a straight-flush!  To a Martian biologist out brain would stand out as an evolutionary aberration if studied in isolation at an individual level.  It is just way too large, complex and costly to be a fluke.  It must be selected by powerful ‘selectors’ – most likely sexual rather than ‘environmental’.

So our brain is the result of either sexual selection, or it conveys some other evolutionary advantage.  (This is clearly a simplistic model. There are millions of genetic switches involved in the construction of a mind.)  The main functions that our neocortices provide which deliver survival advantage are around language, social interaction and our capacity to deal in the abstract.  Crucially we all have a “theory of mind” – that is the capacity to understand the inner workings  of our fellow human’s cognition.  So our brains have most likely evolved in order to allow us to live in complex social groups in which we can collaborate and survive / reproduce at a higher rate.  Socialisation is much more efficient with complex language skills – so our speech and language ‘modules’ are clearly advantageous.  What other “apps” come with our internal software?

Our primordial culture included a good measure of altruism.  Altruism is a behavior by an animal that may be to its disadvantage but that benefits others of its kind.  Basically, “I’ll scratch your back… if you’ll do something of equal value for me later..”  Although we are not purely altruistic – we carry out these acts and have a large capacity to keep a check on who “owes us a back scratch later”.  This is another module in our neocortex that allows us to live in relative harmony and success with large groups of other humans.  Altruism has been demonstrated in many social mammals – and it is well studied in Homo sapiens.  Now, we can imagine where “free will” fits into our understanding of human behaviour.

If we accept that altruism and socially cooperative behaviours are key to our success as a species.  Lets accept that these ‘modules’ allow us to survive as a cohesive family or community group.  The problem is that in order for us to “get along” we need to be conscious of our own actions and those of our friends, tribesmen or foes.  In order for altruism to work, we need a complex ‘theory of mind’.  You might say that being “conscious” is a necessary precursor of any social group.  We also need to have the internal capacity to make our own choices AND to believe that our fellow humans are also acting of their own volition – that they are the masters of their own actions and internal universes.  If our actions were simply a series of unconscious, reflexive motions – then our complex, cooperative  culture would struggle to get off the ground.  In order for altruism to work – I must believe that you want to give me your spare food, and you must believe that I have the conscious capacity to reciprocate.  Enter free will.  If we did not experience life as a stream of conscious events over which we feel we have some degree of control – then we probably would not have the necessary circuitry  to survive as a  closely-knit band of hunter-gatherers on the savannah. But… and it is a big but…  Does the subjective experience of conscious free will, and all of the evolutionary social tools which it allows mean that we actually have conscious control of our minds?

I will argue this.  Free will is a thing.  We certainly have a conscious awareness of our authorship of our actions.  The existence of this subjective experience is a module – an app.  It allows us to perform as a social animal.  More importantly, like to peacock’s tail, this app probably evolved out of sexual selection.  Being altruistic and predictable is quite sexy.  However, free will is the product of evolution. Not some whimsical “higher power” endowed upon us by our ‘soul’.

Look at your smart phone – there are a number of apps running on the desktop.  They are the practical way in which you interact with the unknowable mechanics that go on within your phone’s chip.  However, the app is really just an illusion – a neat trick which allows you to perform certain tasks when you have the need.  Your phone is carrying out all sorts of “unconscious” processes in the background.  Occasionally the software humming away will grab your attention with a alert or buzz – but for the most part it goes along its way without any input from your swipes or gestures.

Our brain is dizzyingly complex. Far more complex than the smartest computer thus developed.  In our unconscious mind there is a constant stream of thoughts, ideas, drives and memories.  A bubbling ocean of activity hidden beneath the surface. When we sleep we dream – an influx of perceptions from deep within the brain itself.  Our experience of this maelstrom of neural activity likely represent s a tiny fraction of all of the data being processed a t any given moment.  Thoughts break the surface, we recognise tham as “our own”, memories are recalled at will… or without any effort.  The smell of popcorn reminds me of the time I snuck into a cinema to watch ‘Terminator‘ before I came of age.  We seem to be able to influence and maintain a grasp on rivulets of consciousness – as I am doing now as I type these words.  The experience is very ‘real’ and yet I wonder… is this the most obvious chicken and egg scenario?  Consciousness and our experience of free will can only have evolved out of a mind that did not possess these “apps”.  They evolved as “add-ons” . Free will is not synonymous with “us” – it is a phantasm.  An unnecessary, yet very useful module of our neurology.

So now, onto the doctorly bit.  We spend a lot of time discussing the concept of Gestalt in the FOAMed community.  “Gestalt” as it is understood in clinical practice is not really what was originally described in the psychology literature.  When we use the term it is really a description of a vague, clinical “spider sense”.  We know what we know… but don’t know why we know it!  We have struggled to describe or understand this phenomenon which we all experience in our daily practice.  My guess is that this thing we call Gestalt is actually our fleeting and tangential awareness, attention to our unconscious minds.  We have massive, complex databanks of similar scenarios and patient encounters stored in our preconscious minds.  These memories and patterns are always there, swirling beneath the surface.   Sometimes, when common or distinctive features are present these are clearly projected into our conscious minds and we can manipulate our actions with our “free will app”.

However, more often the memories and ideas are not prominent enough to be promoted into our attention.  We feel this as a peripheral vision, a misheard thought or a passing urge to act.  It is just off the bank of our stream of consciousness.  This is what I guess Gestalt is.  More experience makes the patterns more vivid.  More mindful clinicians have the ability to divert their attention towards that faint disturbance, hiding on the edge of their field of view.

I believe that to understand this phenomenon and hopefully improve our brains and practice we need to look to neuroscience.  For a long time we have pondered the psychology literature to tackle our biases, errors and risk tolerance.  Recent years have seen a large amount of research into the underlying neuroscience in this field.  It is akin to learning the physics that underpins chemistry.  I hope to start sharing a bit of what I have learned about this fascinating area of research in coming months.  Lets take a look “under the hood” and learn how our brains really work.  Maybe this is another way to improve care and reduce error in Medicine?

If you are interested, come say “Hi” in Berlin or hit me on the comments below.    Casey

Clinical Case 141: Saturnine Palsy

I know – it is supposed to be a Saturday night palsy, but as you know patients rarely bother to read the textbook before injuring themselves or falling victim to circumstance.

I was working on a Monday recently, which is weird as I try to avoid Mondays.  A 23 year old woman presented to ED with a profound wrist drop and some paraesthesia to the dorsal hand.  She was otherwise fit and healthy and had the classic history of having a few too many ales on the night before –  which resulted in her falling asleep in an uncomfortable position of the side of a fold-away sofa bed.

When she woke she felt a dull ache in her upper arm and could not extend her wrist.  She shook it off and tried to do some exercises but 2 hours later it remained quite flaccid to extension and was becoming a bit worrying.

Now if you are not familiar with this syndrome – this is classical “Saturday Night Palsy” of the radial nerve.  Or is it?

I was always taught that this neurological phenomenon occurs when one overindulges in alcohol and falls asleep with the arm draped over the edge of a chair / bench / fence… causing a compression of the radial nerve as it traverses the spiral groove around the humerus.  It is also known as “honeymoon palsy” where newlyweds sleep together in an awkward embrace and one get their nerve squashed in an effort to remain romantically entwined with their new love.  I have also seen the term “Crutch palsy” where folks misuse crutches for leg injuries and place the top buttress of the crutch up into the axilla [not on the chest wall] and squash the posterior cord of the plexus.  We also see traumatic radial nerve injury after fractures of the mid shaft of the humerus – but these are easier to diagnose the cause!

However, the story is as usual – more complicated.  This diagnosis has a rich and long history going all the way back to the ancient Greeks.

Turns out it may have originally been titled “Saturnine paralysis”.  Saturn is the seventh planet and lead was the “7th metal” in ancient times.  So men who drank beer that had settled in pewter mugs were prone to lead poisoning – they were described as being “saturnine” – like the dark and ghoulish Roman God.  The whole Roman Empire may have been in part decayed by the lead in the plumbing [plumbum is Latin for lead, and the root of the English word – plumbing]  This continued through the Middle ages with “adulterated wine” being the source of mass poisonings throughout Europe.  Facial whitening preparations were common sources of lead toxicity in Europe and Asia – Elizabeth the First a notable user / ? sufferer.  In modern times we were still exposing ourselves to lead in paint and fuel additives up until very recently.  In parts of Western Africa the “underground” mining of lead still causes significant burden in the children of the villages.

Lead toxicity, in adults, tends to cause a peripheral neuropathy involving the extensors of the wrist and fingers in the first instance before spreading to other areas. (kids tend to get central CNS toxicity though – see Dr Natalie Thurtle’s SMACC talk on that.)

So how did the term “Saturday Night palsy” enter the English language?  Well, if you believe the etymologists there may have been a confusion between the French ‘paralysis saturnine’ and ‘Saturday palsy’ which over time as the incidence of lead toxicity decreased became synonymous with the modern “Saturday night phenomenon” which still involves the drinking of excessive alcohol, but causes the wrist drop in a more acute and unilateral fashion.  [If you want to read more check out this fascinating article by Spinner et al in NeuroSurgery 2002]

OK, back to the case.  We have a story that sounds like the perfect set up for “Saturday Night palsy” – alcohol to excess, sleeping in an awkward position with pressure on the posterior upper arm.  Her neurological examination showed preserved elbow extension, some weakened supination and flaccid weakness of the wrist and finger extensors.   This is typical for a lesion in the spiral groove below the supply to the tricep muscles. [Han et al have a great review article in Journ Korean Neurosurg, 2014 here]

Schematic radial nerve anatomy and supply. Han et al J Kor Neuro March 2014


Importantly our patient did not have any symptoms and had a normal examination of the other arm…. would be bad to miss the  lead tox!  OR possibly some other symmetrical demyelinating process? One should always keep diabetes, thyroid disease  and B12 in the back of your mind when seeing symmetrical peripheral neuropathies.

So it was a slam dunk diagnosis – clinical medicine, applied anatomy and history all coming to gather to allow me to say – this is a radial nerve palsy….  but before I indulge in too much self-congratulation…  I had to admit that I had absolutely no idea what to tell the patient about what I could do for her or how this was going to to turn out in the future.

So off to the books to learn the facts so I could inform the patient.  Turns out that the data is actually pretty limited – just a few case series and reviews, mostly with a strong neurological theme of looking at action-potential conduction recovery rather than patient recovery!

The news is good – the vast majority of patients with “non-traumatic” radial nerve lesions make a full recovery.  As one would expect it does take time for the nerves to regenerate – and the studies I read ranged from 2 weeks out to 6 months for a full recovery of function.  The mean duration of symptoms was around 3 months in most reports.  So what can we do in the meantime?

The mainstay of treatment involves:

  1.  Splinting to maintain the tendons, joints and allow some function as the wrist drop resolves.  Our best friends here at the OTs or hand therapists.  They can make customised, dynamic hand splints that keep the joints moving and allow exercises which maintain the tendons etc.
  2. Passive exercises to keep the muscles moving and avoid atrophy where possible to enhance recovery as the nerve supply comes back online.

So when I discussed this case with the “local” Neurologist (2000 km away) they were keen to get an MRI and nerve conduction studies.  This seems like a good idea, mainly to exclude other nasty or unexpected causes of nerve compression.  However, I do wonder, in a disease with such a good prognosis and relative fast recovery where the diagnostic testing is unlikely to change our immediate management… is it really worth it?

Would it be best to do all the tests up front?  Or should we reserve these for cases where there is not recovery as expected or the story doesn’t make sense in terms of aetiology?

Let me hear your thoughts.




First10EM Journal Club: May 2017

We are back with another set of papers to dissect, discuss and digest.  Justin and I have been working on a few big projects and are in full prep for the upcoming DasSMACC meeting in Berlin. We managed to skip April, but we are planning something a little special for June in Berlin.

If you are a fan of the podcast / journal club and will be at DasSMACC – then you can join us behind the mic and share your ideas on any paper you choose – just get in touch. Comments section will be easiest

This month we review papers on PPH, Wellen’s,  CO tox, ambulance communication and more.  As always, the papers are right here in full PDF for free… so do your own reading and think critically.  You can read Justin’s refined written thoughts over at First10EM now!


WOMAN trial collaborators . Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet (London, England). 2017

Olaussen A, Nehme Z, Shepherd M. Consciousness induced during cardiopulmonary resuscitation: An observational study. Resuscitation. 2017; 113:44-50.

Morris N, Howard L. BET 1: In patients with suspected acute coronary syndrome, does Wellens’ sign on the electrocardiograph identify critical left anterior descending artery stenosis? Emergency medicine journal 34(4):264-266. 2017.

ACEP, Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning.  Annals of emergency medicine. 2017; 69(1):98-107.e6.

I also mentioned this Taiwanese retrospective trial of HBOT on CO tox (Chest 2017)

Verma AA et al. Pulmonary Embolism and Deep Venous Thrombosis in Patients Hospitalized With Syncope: A Multicenter Cross-sectional Study in Toronto, Ontario, Canada. JAMA Intern Med. Published online May 08, 2017.

We also briefly mentioned the RESPECT-ED trial on Australasian PE investigation (Dr David Mountain et al, Plos One 2016)

Cram N, McLeod S, Lewell M, Davis M. A prospective evaluation of the availability and utility of the Ambulance Call Record in the emergency department.   CJEM. 2017; 19(2):81-87.

Andersen LW, Granfeldt A, Callaway CW. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017; 317(5):494-506.

Okumura T, Suzuki K, Fukuda A. The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response.   Academic emergency medicine. 1998; 5(6):613-7. 
Okumura T, Suzuki K, Fukuda A. The Tokyo subway sarin attack: disaster management, Part 2: Hospital response. Academic emergency medicine. 1998; 5(6):618-24.

See you in Berlin…

Casey & Justin