Special thanks to EMRA, Dr. Scott Johnson, Dr. Michael Beck, Dr. Scott Weingart, and the Stony Brook University Emergency Medicine Residency Program.

Optimizing Emergency Medicine Performance in Stressful Environments from EM Residents’ Association (EMRA) on Vimeo.

Imagine

Imagine.
Imagine this is how it starts.
A shout for the code cart
And all of a sudden, your heart jumps out like Mario Kart.
Your pupils dilate
And your hands begin to sweat.
Cortisol spikes and epinephrine surges.
Every muscle in your body, every sinew, every fiber tightens and merges.

And it’s hard to take a breath
because Death is at the door step,
his hot whisper at your neck.

All of a sudden
the patient stops breathing,
your mind ceases reasoning,
people start screaming,
the monitor is beeping,
Rome is burning,
the Titanic is sinking,
and everyone is looking,
wondering,
what is this man thinking?

The first step is airway so
Stop.
Take a breath.
First for yourself,
and then for your patient.
Slow down.
Take appraisal.
For how are you going to save this woman’s life
if you go on and vagal.
Inhale.
Exhale.

This is the medical emergency you fear the most.
It’s the procedure you haven’t done in years.
Perhaps you’re sectioning a belly or cracking a chest,
everything depends on this vital test.
Or you shall be introducing her family, her hopes, her dreams,
to your most reliable colleague, the ever present Death.

Ladies and gentleman,
this is the definition of high stress, high stakes.
Game 7. Bottom of the ninth.
Fourth quarter, fourth down, fourth and goal.
Clock running out.

And according to experts:
“Pressure…
is due to a perceived imbalance between the demands of the emergency situation, and your ability to meet those demands, where failure to do so has important consequences for you.”
In other words:
The task is important.
Your abilities are in question.
And your reputation depends on it.

The problem
is that pressure is inversely related to volume.
So as her sat start dropping,
and her QRS start widening,
the world starts inward closing.
And the man in your head,
hooked up to an IV of self-doubt,
is pressing eject.
Your memory begins to stumble.
and Logic takes a cigarette break.
And just before the proverbial melena hits the fan…

You hear a voice.
Whose voice?
Your voice.
There are many like it but this one is yours.
What do you hear?
Tranquilo. Relax.

Yes we can.
In fact, motivational self-talk has been proven to improve the performance of elite athletes, warriors, and presidents.
Yes we can.
But to hear it you must listen.
The first step towards humility.
The next step towards optimizing performance.
So say it loud and trust yourself when you hear yourself.
I got this.

But right before you make a move,
you realize the wires are crossed
and your brain is short circuiting.
What comes before who?
And where was that other thing?

So you close your eyes
and see symphony number five.
This is your magnus opus.
Your Mona Lisa.
Your Michelangelo.
Your one last shot
before Dante’s Inferno.

And now you are finally starting to see
like Neo, Morpheus, and Trinity.
Each step giving rise to the next,
each action fluid and precise,
and each moment with clinical clarity.
From getting buckets to bedside surgery,
the psychological key
to enhanced motivation,
improved concentration,
and optimized preparation,
is the time-test art of visualization.

So there you are,
breathing deep and getting hyped.
But the Man in Black has arrived
and he’s wielding a scythe.
It’s your last chance to reverse your patient’s damnation,
give her a chance for an ultimate salvation.
Are y’all ready for this?

It’s game time
and there’s ice water in your veins.
Clear eyes, full hearts, can’t lose.
Float like a butterfly, sting like a bee.
If there’s a will, there’s a way.
Power pose. Power play.
Snap your fingers and you become unflappable.
Focus your mind, and Alakazam!
You’re now unstoppable.

Because it’s about mindfulness on full blast,
it’s about coming up with a cue.
Whether it’s a word, a phrase, or even a dance move,
just make sure you practice it before you do what you do.
It’s about summoning Pavlov
and giving a dog a bone.
It’ about saving your patient’s life
by getting in the zone.

And when the moment of truth at last arrives:
Inhale. Exhale. I got this. Then visualize.
Run the checklist to this manifesto in through your mind.
Power pose. Focus word. And then it’s ready, set, go time.

The world goes silent, as your brain locks in.
Your hands glide smoothly, fluent in medicine.
You’re a composer. A maestro. A skilled practitioner.
Even Death knows the score, you’re his executioner.

Exactly as planned, everything fall to place
You check the monitor as her heart begins to pace.
Your fingers are steady, your mind is clear.
It’s because you’ve trained, that you have no fear.

She catches her breath, and as her second life blooms,
a woman starts to cry from the corner of the room.
You catch her eye, looking through at you,
it’s the patient’s mother, who whispers, “Thank you.”

Let’s pause and reflect for just a second.
Let’s talk about the gravity of this essential lesson.
A wise man once said,
We don’t rise to the level of our expectations
We fall down to the level of our preparations.

So ask yourself,
what kind of doc do I want to be?
Do I want to be nervous and scared,
acting indecisively?
Or do I want to be relaxed and confident,
like a professional should be?

You have the choice.
You’re in control,
positive or negative,
on how your fate unfolds.

So to recap,
Breathe to regulate your physiologic response in high stress situations.
Hear yourself talk your way to positive affirmations.
Visualize the steps to rehearse them before you execute them.
And bring yourself to mindfulness to Focus on what’s most important.

Do that and watch yourself rise to the moment.
Go ahead…
and just imagine.

 

References:
  1. Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Annals of Emerg Med. 2017; 70:884-890.
  2. Weisinger H, Pawliw-Fry JP. 2015. Performing Under Pressure: The Science of Doing Your Best When It Matters Most. New York, NY: Crown Publishing.
  3. Morgenstern J. (2017, March 13). Performance Under Pressure. Retrieved from https://first10em.com/performance-under-pressure/
  4. Lauria MJ, Rush S, Weingart SD, et al. Potential Role for Psychological Skills Training in Emergency Medicine: part 1 — introduction and background. Emerg Med Australas. 2016; 28:607-610.
  5. Birrer D, Morgan G. Psychological Skills Training as a Way to Enhance Athlete’s Performance in High-Intensity Sports. Scand J Med Sci Sport. 2010; 20:78-87.
  6. Whitelock KA, Asken MJ. Code Calm on the Streets: Mental Toughness Skills for Prehospital Emergency Personnel. Mechanicsburg, PA: Sunbury Press; 2012.
  7. Sugar R. (2015, July 27). 13 Secrets for Performing Better Under Pressure. Retrieved from https://www.businessinsider.com/how-to-perform-under-pressure-2015-7
  8. Robson, Sean and Thomas Manacapilli, Enhancing Performance Under Stress: Stress Inoculation Training for Battlefield Airmen. Santa Monica, CA: RAND Corporation, 2014. Retrieved from https://www.rand.org/pubs/research_reports/RR750.html.
Photo Credits
  1. Trauma Bay 3 at Stony Brook University Emergency Department – Courtesy of Michael Beck, MD
  2. https://www.gettyimages.com/detail/photo/high-as-a-kite-royalty-free-image/181147102
  3. https://unsplash.com/photos/OwqLxCvoVxI
  4. https://unsplash.com/photos/fGUmhLROnPc
  5. https://unsplash.com/photos/tkr3hrDxdRk
  6. https://www.shutterstock.com/image-photo/basketball-players-on-big-professional-arena-1184799064
  7. https://unsplash.com/photos/FpE8zczkufQ
  8. https://www.shutterstock.com/image-photo/bursting-balloon-102179608
  9. https://unsplash.com/photos/mp_FNJYcjBM
  10. https://www.shutterstock.com/image-photo/charlotte-nc-usa-july-5-2016-448638580
  11. https://www.shutterstock.com/image-vector/glitch-abstract-shapes-chaos-pixel-cyberpunk-1075392494
  12. https://www.shutterstock.com/image-illustration/signal-oscillation-optical-flow-series-background-1475514731
  13. https://www.shutterstock.com/image-photo/surgeons-perform-brain-surgery-using-augmented-1152709331
  14. https://www.shutterstock.com/image-photo/grim-reaper-on-road-79847011
  15. https://www.shutterstock.com/image-photo/african-woman-stretching-arms-beach-fitness-1038983215
  16. https://www.pexels.com/photo/person-holding-round-framed-mirror-near-tree-at-daytime-979927/
  17. https://photos.com/featured/close-up-of-surgical-instruments-on-medical-tray-morsa-images.html?product=art-print
  18. https://unsplash.com/photos/rvsQLewSqH4
  19. Aftermath in Trauma Bay 3 at Stony Brook University Emergency Department – Courtesy of Michael Beck, MD