emDOCs Podcast – Episode 122: Performing Under Pressure

Understanding Crisis Performance

• Myth of the “Clutch Performer” – debunked
  • High pressure reduces performance
  • Data shows we fall to the level of our training
  • No one is immune—everyone is affected

How Our Brain and Body Reacts

Threat vs. Challenge Assessment

Threat-Demand greater than resources

• Fight, flight, or freeze
• Common in medical settings: freeze response most likely

Challenge -Resources greater than Demand

• Viewing crisis as challenge (not threat) improves performance

Physiological Heart Rate Stress Zones

• White zone: Resting HR, low cognition
• Yellow zone: Optimal arousal and performance
• Red/Black zone: Severe cognitive and motor breakdown (vomiting, tunnel vision, syncope)
• Goal: Stay in the Yellow zone

Performance Breakdown Under Stress

• Fine motor skill loss (e.g., difficulty with tools like central line wire)
• Attention narrowing (tunnel vision, auditory exclusion)
• Time distortion (e.g., excessive BVM squeezing)
• Working memory reduction (cognitive bandwidth drops)
• Decision-making errors (heuristic lock-in, inflexible thinking)
• Team dynamics suffer (leader stress impacts the whole team)

Extending the Optimal Performance Zone

• “Goldilocks Zone” of arousal = optimal performance range
• Can be expanded with training
  • Not a fixed peak—can become a broader, stable plateau

Just In Case Preparation

Concept Introduction: Just In Case Preparation

• Analogy: Think of it as rehearsal – both physical and mental

Physical Rehearsal: Training Crisis Procedures

Training Plan: Goal: Over learn Procedures for Automatic Response

1. Choose high-stakes procedures (e.g., Intubation, Cricothyrotomy, Central Lines, Minnesota Tube)
2. Break It Down
   • Incrementalization (Concept by Rich Levitan)
   • Break procedure into small, sequential steps
     • Steps should be:
       • Best practice
       • Reliable
       • Reproducible
3.  Identify Micro-skills

• Match physical skills to each step
  • Examples:
    • Syringe disconnect in Seldinger technique
    • Index finger movement during Cricothyrotomy
• Focus practice on these micro-movements

Translating Practice into Performance: Deliberate Practice

What is Deliberate Practice?

• Choose a specific incremental step to improve
• Give it full attention
• Attempt the task
• Get immediate expert feedback on:
  • What went right
  • What went wrong and why
• Repeat and refine the step
• Note: It feels slow and uncomfortable — that’s real learning

The Risk of False Reinforcement: BDGO & BTGO

A. Definitions:

• BDGO: Bad Decision, Good Outcome
• BTGO: Bad Technique, Good Outcome
• False reinforcement of poor habits if outcomes are favorable despite errors

B. Real-World Risk:

• Learners may believe they did the procedure correctly just because the result was successful

C. Solution Example:

• Use standard geometry video blades and objective visual aids to:
  • Assess actual technique
  • Avoid reinforcing incorrect habits

Mental Rehearsal

1. Introduction: Mental Preparation as Rehearsal

• Just like physical practice, mental rehearsal ensures we’re ready before the chaos hits.
• Mental rehearsal = retrieval practice
• Recognizes that decision-making and working memory will be throttled under stress.

2. Building Mental Models

• Pre-plan how you’ll handle critical situations using best practice-based mental blueprints.
• Examples:
  • Crashing anaphylaxis
  • Afib with RVR + soft BP
  • Drug choices for status epilepticus
  • Ventilation strategies for asthmatics

3. Pre-Made Decision Paths

• Avoid decision paralysis during crises.
• Design decision trees with built-in reassessment checkpoints, e.g.:
  • Before moving to CT
  • Post-intubation reassessment
  • WHEN WILL I CRIC

4. Troubleshooting and Decision in Advance

• Example: Airway Plan
  • Start with standard geometry + bougie
  • Use video/direct laryngoscopy as needed
  • Have a backup plan (e.g., hyper-angulated blade, supraglottic, cric)
  • SPO2 trigger = pre-planned action (e.g., place supraglottic device at 92%)
• Team sharing of mental models:
  • Announces intentions
  • Aligns team
  • Offloads cognitive burden

5. Cognitive Offloading

• Mental overload is real – free up bandwidth for diagnostic reasoning.
• Use external tools as second brains:
  • Checklists
  • Drug cards
  • Braslow tapes
• These tools support, not replace, expertise — use them proactively.
• Be familiar with them before you need them (e.g., don’t first open Braslow tape during a pediatric code)

6. Strategy vs Logistics

• Strategy = Clinical decision (“I need a cordis”)
• Logistics = Execution (“Where is the kit? How do I set it up?”)
• Mentally rehearse logistics in advance: visualize gathering and using supplies
• This reveals gaps in knowledge or prep before it counts

7. Emergency Reflex Action Drills (ERADs)

• Concept by Weingart, Laurie, and Cliff Reid
• Fixed action patterns for time-sensitive emergencies
• Goal: Bypass active cognition during crisis
• Examples:
  • About to die hypotension → Cart-Epi-Half
  • Drop-off code → Compressions, Bag, Pads
  • Sudden unconscious STEMI → Pads-Rhythm-Shock

8. Designing Your Own ERADs

1. Identify a time-sensitive emergency
2. Design an evidence-based response
   • Use guidelines or expert consensus when no hard data exists
3. Ask: What are the critical first steps that buy time?
4. Incorporate logistics: Know where things are and how to access/use them
5. Train your brain: If you have to think about your ERAD in the moment, it won’t work

9. Visualization

• Leverage your brain’s internal simulator:
  • Activate the same pathways as physical practice
  • Step-by-step, immersive mental walk-throughs
  • Works for procedures and full resuscitation scenarios
    • Example: Visualize being the trauma team leader

10. Fear List: Let Fear Guide Preparation

• Identify what scares you the most — high-risk, low-frequency events
• Make a list
• Turn these into your preparation priorities

11. Make It Happen: Training Schedule

• Build rehearsal into your life
• Schedule practice outside shifts (calendar event, phone reminder)
• Use tools like Anki for spaced repetition:

12. Final Thoughts

• Mental preparation is not about removing thinking — it’s about thinking ahead.
• The combination of mental models, ERADs, logistics practice, and cognitive offloading tools allows you to perform under pressure without needing to “figure it out” in the moment.

Just In Time

• “Just in time” techniques for chaotic moments
• Trial these during high-stress times: sim lab, busy shifts, real resuscitations
• Must be practiced to be effective
• Based on performance psychology in high-stakes environments

4-Step Performance Process (Lauria et al., 2017)

Beat The Stress Fool

1. BREATHE

• Regain control by controlling breath
• Stress leads to shallow breathing—must counteract this
• Controlled Breathing Pattern:
  • Inhale, Double Exhale Time
    • Inhale through the nose (e.g., 5 seconds)
    • Exhale through pursed lips (e.g., 10 seconds)
  • Can also use tactical/box breathing (4-4-4)
  • Regulates heart rate, calms body and mind
  • Practice b

2. SELF-TALK

• Internal dialogue
• Types:
  • Motivational/self-affirmation: “I’ve trained for this”
  • Instructional: Step-by-step mental model
  • Reframing: Change your perspective on a stressful situation
  • Incrementalization: Break into small, doable steps
• Guidelines:
  • Use short, positive, present-tense phrases
  • Say them intentionally and repeat
  • 3rd Person

3. SEE (Visualization)

• Mentally simulate the procedure
• Engages the same neural networks as real action

4. FOCUS WORD

• A cue word to bring you back into a flow state
• Examples: Focus, Smooth, Breathe
• Condition yourself to use this during calm, controlled moments so it becomes a reset trigger in chaos

Beat The Stress Fool

Post-Crisis: Managing the Aftermath

1. Parasympathetic Backlash

• After adrenaline, body crashes → situational awareness drops
  • Don’t “drop the mic” after a win (like an intubation)
• Return to your primary survey/checklist
• Use cognitive rally points
• Reassess patient thoroughly
• After if no one is critical- Recharge
  • Water
  • Snack
  • Caffeine

2. Incomplete Adrenaline Dump

• When anticipation doesn’t lead to action (e.g., code canceled)
• Body still flooded with stress hormones
• Must actively down regulate:
  • Move (walk, pushups, stretch)
  • Go Outside
  • Keep doing controlled breathing
  • Let adrenaline “burn off” constructively

Resources:

Stimulus Podcast- 115-Zero Warning | Scott Weingart on frameworks for no-notice critical patients

115. Zero Warning | Scott Weingart on frameworks for no-notice critical patients – Orman Physician Coaching

Stimulus Podcast-123- How to Create a Team in 10 Seconds

123. How to Create a Team in 10 Seconds | Why time is not linear and every second not worth the same – Orman Physician Coaching

Mike Lauria- Emergency Reflex Action Drills

Emergency Reflex Action Drills

Mike Lauria. The Necessity of Emergency Reflex Action Drills. EMCrit Blog

The Necessity of Emergency Reflex Action Drills

EMCrit RACC Podcast 220 – Beat the Stress Fool (BtSF) with Mike Lauria — Just In Time Performance-Enhancing Psychological Skills.

EMCrit 220 – Beat the Stress Fool (BtSF) with Mike Lauria — Just In Time Performance-Enhancing Psychological Skills

Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset.

EMCrit 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset

Scott Weingart. EMCrit Podcast 49 – The Mind of a Resus Doc: Logistics over Strategy.

EMCrit 49 – The Mind of a Resus Doc – Logistics over Strategy

Scott Weingart. Podcast 164 – The Day I Didn’t Use Ultrasound by Mike Mallin.

EMCrit 164 – The Day I Didn’t Use Ultrasound by Mike Mallin

Scott Weingart. Podcast 99 – Combat Aviation Paradigms for Resuscitationists.

Podcast 99 – Combat Aviation Paradigms for Resuscitationists

Paper Review – The Human Factor

Practicing Rare Procedures

Performance Under Pressure (how to manage stress) – First10EM

Beyond ACLS: Cognitively Offloading During a Cardiac Arrest – REBEL EM – Emergency Medicine Blog

EMCrit 293 – The Jerk & Check, Functional Heuristics in Resuscitation Project (MotR)

EMCrit 339 – Decisions, Decisions, Decisions with Andrew Petrosoniak

The Resuscitationist’s Mindset

Episode 86: Scott Weingart MD FCCM from EMCRIT.org on Maximally Aggressive Care

EMCrit 163 – MotR – The Post-Resuscitation – Recovery after Resus

Mental Practice: Applying Successful Strategies in Sports to the Practice of Emergency Medicine

https://pubmed.ncbi.nlm.nih.gov/38244027/

Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress

https://emcrit.org/wp-content/uploads/2017/05/PEP-under-Stress.pdf

The Human Factor: Optimizing Trauma Team Performance in Dynamic Clinical Environments

https://pubmed.ncbi.nlm.nih.gov/29132571/

Cric Training

https://emcrit.org/emcrit/how-to-teach-surgical-airways/

Books

Performing Under Pressure: The Science of Doing Your Best When It Matters Most by Hendrie Weisinger J. P. Pawliw-Fry

https://www.amazon.com/dp/B00N6PESWC/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1

On Combat, The Psychology and Physiology of Deadly Conflict in War and in Peace by Dave Grossman, Loren W. Christensen

https://www.amazon.com/Combat-Psychology-Physiology-Deadly-Conflict/dp/0964920549

Peak: Secrets from the New Science of Expertise by Anders Ericsson, Robert Pool

https://www.amazon.com/Peak-Secrets-New-Science-Expertise-ebook/dp/B011H56MKS/ref=sr_1_1?keywords=peak+performance+expertise&qid=1574266855&s=books&sr=1-1

The Emergency Mind: Wiring Your Brain for Performance Under Pressure -Dan Dworkis

https://www.amazon.com/Emergency-Mind-Wiring-Performance-Pressure/dp/B094GY88RK/ref=tmm_pap_swatch_0