57. Cultivating the Emergency Mind | Graduated pressure, sangfroid, and acknowledging the suboptimal

• Any time you’re in a situation which is dangerous or where you’re uncomfortable, take stock of what you’re doing and figure out what is or isn’t real.
• The same countermeasures you train for in martial arts when you’re under attack, for example, can be used in almost any other setting. Recognize what you have available to focus on (ie. your breath, your pulse) and remember that you’ve gotten out of intense situations in the past.
• “Start by taking your first movement toward something. Once you start moving, you can pivot, adjust and do everything better. But you can’t stay still. If you stay still, you’ll freeze and crumble.”
• Part of coming back to center is moving away from whatever is causing your panic — engaging in action rather than staying static.
• The Upside of Stress by Kelly McGonigal talks about the different ways that our physiology can respond to stress. There are many options, we just have to be able to choose them.

• For an emergency provider, there are numerous potential stressors (a critically ill patient, a packed waiting room, a difficult procedure). Different situations call for different types of responses, and we need different tools in different circumstances.
• The skills needed to succeed in a mission critical moment are different from those needed to do well when the pressure is low. At the same time, they’re not entirely separate because they’re all linked together.
• We need to be aware of how our brain and body work under pressure to understand how we function. Some of it is related to how our brain is wired.
• Accessing and applying knowledge under significant pressure is difficult, but it’s a skill one can get better at. There are different mental models for accessing that knowledge.

• System 1 thinking is automatic processing, easy flow pathways, and deep algorithms. System 2 is more creative, analytic, and exhaustive in its processing.
• The brain is a connection of pathways, and not all pathways are equally easy to down. We’re wired to be really good at some things depending on the circumstances and the type of energy required.
• Daniel Kahneman’s book, Thinking Fast and Slow, describes the anisotropy of how information flows through the brain — it does not flow easily through all parts of the brain the same way. Some things are easier for you to think than others.
• Gary Klein disagrees with the concept of system 1 and system 2 thinking and offers a different algorithm in Sources of Power — the recognition-primed decision-making model.
• While Kahneman’s model looks at how people that are not experts make decisions about things that are new to them, Klein’s theory describes how experts make decisions in fields where they have expertise.

• Time on target and repetition are necessary but not sufficient to become a master. We have to do more than just show up for work in order to actually achieve mastery.
• We know that time on target isn’t enough because the most experienced are not always the best.

• The concept of graduated pressure is that you need to master your skill in a friendly, ultra-low stakes environment and then ramp up the pressure over time until you’re ready to apply it in real life. This allows us to address that circumstance in a logical way that gets us ready to perform at the top of our level. The counterfactual to that is jumping in the deep end.
• We do this because we want to capture information from our failures and never waste that suffering.

“Suffering happens. It’s an inevitable part of existence. But if we leverage it and get better, then it has worth.”

• At a physiological level, when we feel pressure our sympathetic nervous system is firing. Our heart rate increases, we sweat, we’re tense. We have to overcome this physiology when we want to deploy knowledge expertly.
• The idea of borrowing pressure is to leverage other experiences where you feel those things and train in those circumstances. For example, do a mental simulation of a difficult task when your system is activated after running up a steep hill.
• Other techniques are 1) to visualize under pressure and 2) to learn transferable tools that work in all sorts of pressure situations.

• This describes the bell-shaped curve where the x-axis is essentially cognitive load. The further you’re out on the x-axis, the more pressure you feel. On the y-axis is your performance at a particular task.
• If there’s not enough pressure or load, then you’re bored and you don’t perform well. But if there’s excessive pressure, then you’re frazzled and (again) perform poorly. The sweet spot is somewhere in the middle.
• We can employ countermeasures to left shift us on the curve when we’re overwhelmed and right shift us when we’re bored. It helps to break complex tasks into small incremental segments.

 

 

 

• Sangfroid is a French term that literally translated means cold-blooded, but really refers to the skill of being calm and composed in stressful situations. At a fundamental level, sangfroid is not being perturbed by present cricumstances.
• Sangfroid is a package of skills that can be deployed in response to pressure: physiologic skills (like controlling your breathing), mental skills (like using Stoic principles to slow down and control the pause between stimulus and response), and interpersonal communicative skills (like communicating in a way that radiates calm).
• You can practice the skills in small circumstances, such as when coffee spills on you, and then deploy them iteratively in increasing pressure situations.

“Sangfroid is a trainable skill, and the way to train it is graduated pressure.”

• The path to excellence is more than the technical ability required to complete a task well. It involves doing your work quickly and efficiently, while bringing joy, creativity and peace.

“When I think about what the paragon of being an emergency doctor is, I think about sangfroid. I think about the ability to be there to help anybody that comes in no matter what they need, but also the ability to do that with joy and warmth.”

• Along the way of trying to achieve excellence, you will stumble and fall. What do you do when things don’t go the way you want? Some will get frustrated and make “the second mistake”. James Clear writes about avoiding the second mistake.
• When something goes wrong, you have a choice of either using a package of skills to allow you to move forward stronger than when you started, or you can make things worse by suffering a second mistake that makes things worse.
• For Dan, by saying out loud, “Well, this is suboptimal”, he recognizes the severity of what happened, yet resets for the next moment. “You recognize this is the reality, and you meld with that reality and move forward.”

• Your tired moves and the moves that work no matter how stressed you are or how broken things are around you. These are your core basic principles and you have to be adept at them before you even think about your fancy moves.
• In the emergency department, the tired moves are what work when you’re 8 hours into the shift, exhausted, out of coffee, bloodied, and the next two trauma patients roll in together.
• We have to train in a way that allows us to function in these circumstances. In addition, we must recognize when we’re not in our ideal state and adjust accordingly. “Part of the tired move is just acknowledging that you’ve got less in the tank.”

“None of us are immune to physiology. To think that we are or to think that it’s a personal failing really sets us up for an unnecessary failure. With a simple act of reframing and designing systems that support you when you’re tired, you can set yourself up for success.”

• Become a student of yourself and know how you perform and function under pressure. Every person responds to pressure and to stress differently. Ultimately, it’s on you to figure this out for yourself. Start experimenting, testing hypotheses, applying graduated pressure, and running your own experiments on yourself. Keep track of what happens so you can figure out what works.