The Emergency Mind:Wiring Your Brain for Performance Under Pressure

By Dr. Dan Dworkis 

This book is about training to bring your skills to bear when the heat is on and wiring your brain to perform at your best during times of crisis.

I wrote this book because I believe deeply that your ability to perform when it matters most depends directly on how you think, act, and train now, before an emergency strikes.

While you cannot control what emergencies come your way, you do control how you prepare; you control what you do now to build your emergency mind and wire your brain to perform under pressure.

In or out of the emergency department, all emergencies share three common structural characteristics: 

• Emergencies involve uncertainty. 
• Emergencies have high-impact outcomes. 
• Emergencies occur under significant pressure.

 

While uncertainty can never be fully eliminated, it can sometimes be reduced by trading time or resources for more certainty.

 

Outside View

• The potential impact of a situation almost always feels larger from the inside than it does from the outside. Gaining accurate “outside view” information on our situation is crucial to mitigate the sometimes disproportionate “inside view” effects of a personally significant potential impact.

Handling your fear and pressing forward anyway is always a better answer than paralysis.

• Your physiological readiness to handle complex loads also influences the pressure you experience during a crisis. Low stocks of internal resources such as nutrition, hydration, sleep, and recovery negatively affect performance and increase the pressure you feel. External factors like temperature, noise, or light conditions may also play a role in diverting your attention and increasing your cognitive load.
• Importantly, you typically feel pressure relative to your available resources, not on absolute scale. Maximizing your available resources before and during a crisis, and improving the efficiency of their use, can therefore reduce your perceived pressure. For example, if you were given ten seconds to cut through a rope, you would feel much more pressure if you had a butter knife than if you had a sharp razor blade. Accordingly, several of the mental models we explore in this book work both with reducing sources of pressure and improving resource availability.
• Maintaining an honest appraisal of the levels of these factors present in a situation can alert you to opportunities to improve your training and ability to perform during crises.

FIND THE CALM IN THE STORM 

• Where beginners see only chaos, experienced emergency providers are able to see the underlying “rhythm” in a crisis and identify time to think and act in even the worst situations. Finding these moments of calm during a crisis allows you the space to analyze your progress and pivot your response to more productive directions. When calm moments do not naturally occur, experts can use focused training and well-designed systems to create them.
• With practice, your thoughts and actions become centered on rhythm and flow over raw speed and force. Your strategies are built not on taking more actions, but on slowing down to identify and then execute only the best possible actions for that patient in that moment.
• To accomplish this, the best leaders actively seek out and build moments of calm into even the most chaotic and critical cases.
• This is a lot of work to accomplish, especially if you are in “full sprint” or panic mode throughout the cycles. Carving out calmer spaces to think, process, and plan allows you and your team to absorb new information and provide better care during the next cycle.
• Logistically, capitalizing on calm moments in the midst of complex emergencies involves identifying existing moments of calm during a case and purposefully training to generate new ones.
• With practice, you can reframe this extra time as “moments of calm” and train yourself to identify the moments that already exist between decisions. These bits of time become spaces in which you can think and recover— much in the same way that expert athletes train to utilize time between plays for reset and reflection.
• Similarly, rapidly identifying decisions that do not need to be made in a particular moment leaves more mental energy available for the decisions that do need to be made. Automating certain processes—like by-default activating appropriate intensive care staff when a patient arrives in the emergency department in cardiac arrest—removes the need for some decisions.
• Finding calm in the midst of chaos is not easy, but it is something you can work to improve. To paraphrase the Stoic philosopher and Roman emperor Marcus Aurelius, “The closer a person is to calm, the closer they are to strength.”
• It is only by starting to look for and use moments of calm during a crisis that you will find this source of strength. So, the next time you find yourself in a tense but non-emergency situation, look for and attempt to generate moments of calm. Afterward, reflect on the resulting experience. You likely will be surprised how situations that initially feel like chaotic sprints actually have an underlying rhythm and natural spaces to think.

02 BECOME A STUDENT OF SANGFROID 

• Sangfroid—translated literally as “coldblooded”—is the ability to be calm under significant pressure. While it might seem like sangfroid is an innate talent only a few possess, it actually is a skill that anyone, including you, can develop. Time spent working on your craft is necessary but not sufficient to develop this ability. Mastering sangfroid requires deliberate practice involving experimentation and dedicated training under pressure.
• First, sangfroid is not a fixed personality trait that you either have or you don’t.
• Second, while deep experience in a field makes sangfroid easier to develop, sangfroid does not develop passively as a byproduct of training other skills.
• Conscious, deliberate training that is explicitly focused on high-pressure performance is required. If building sangfroid were to happen passively as you train other skills, then the oldest people in the room—those with the most time spent training—would always be the coolest under pressure. Instead, it is the people and teams who specifically practice sangfroid who perform the best during a crisis.
• The first step in training sangfroid is to develop a sense of how you currently respond to pressure.
• Second, identify different models for more effectively responding to pressure. Some of these models might be small iterations on actions you’re already taking. For example, you could take three deep breaths for three counts each, instead of just any deep breath. Perhaps you could modify the tone of your voice or practice saying slightly different words when you address your team. Again, the more detail you capture with each of these models, the better. When starting to consider techniques that are very far from what you currently do, try to identify small steps or subprocesses that can bridge you from what you do now to what you want to attempt.
• The third and most important step in developing skill at sangfroid is experimentation. You have to consciously practice different techniques of performance under pressure to find what works best for you.
• Perfect mastery is not the goal; continued study and improvement is.

One important note: The process of developing sangfroid is not at all linear and comparing your progress to that of others after a set amount of time might set you up for disappointment or failure. Milestones in structured training are of course important, but sangfroid is intensely personal; at its core, it is about who you are and how you relate to the universe. No one can teach you sangfroid, it is up to you to choose to study it.

 

• When you’re ready to begin experimenting, don’t start in ultra-high pressure, life-or-death situations. Instead, start the experiments when you feel pressure during your everyday life— “When I feel pressure, I will take a breath, pause, and then physically move toward the problem.”

 

03 PRACTICE THE DISCIPLINE OF “SUBOPTIMAL” 

• High-quality responses to errors, bad outcomes, or challenging situations move past fear or anger to focus on what comes next. Emergency providers use a three-step approach: 
  • identify and accept the issue or mistake, 
  • rapidly pivot yourself and your team to face the new reality
  • learn from the event to evolve improvements for future cases. Steps one and two are performed in the moment, while step three is performed after the crisis has passed.

• When bad outcomes do occur, you need to be able to react to them in a way that moves you and your team past the initial wave of negative emotion and toward a more productive response.
• A skilled response to a bad outcome involves three parts: labeling, processing, and learning.
• Personally, when I perform the labeling part of a response, I begin by saying, “Well, this is suboptimal.” Labeling something as “suboptimal” acknowledges the challenging nature of what is happening without pulling me or my team off-line the way that calling it “horrible” or “hopeless” might.
• The second step in processing a challenging (read “suboptimal”) situation is to identify your new priorities and pivot your team into their new roles and actions. A potentially counterintuitive first move in this process is the action of pausing and breathing. It might seem like immediate action is always necessary after a bad outcome, but often the initial thoughts that dominate after a setback are blunt and reactive concepts that lack skill or nuance.
• Simple, direct commands are important, as is explicitly sharing your mental model with your team to ensure everyone is on the same page. Calm delivery is again key, and closed-loop communication—in which the receiver echoes back key information—can be extremely useful.
• If the crux of the situation can be easily identified, it’s often sufficient to take two to five minutes after clearing the event to debrief and generate ideas for future work. Before the debrief, encourage your team members to hydrate, visit the bathroom, or otherwise take a moment to regroup. This will usually result in calmer, more mentally flexible individuals who generate better ideas than attempting an immediate debrief without taking a break.

04 APPLY GRADUATED PRESSURE 

• Building your emergency mind requires deliberately practicing skills in pressure-filled situations, not just in calm conditions. Excessive stress early in learning, however, is counterproductive and potentially even dangerous. Emergency providers utilize graduated-pressure protocols to first learn the basics of a skill then adapt it in increasingly pressurized environments. One of the key advantages of this approach is its ability to sequentially identify which components of a system fail at which levels of stress, and which components are ready to be deployed.-applying too much stress too quickly can limit learning or even lead to dangerous conditions.
• To find that middle ground where training is effective but safe, emergency medical providers apply the concept of graduated pressure to slowly and safely test and improve a skill before relying on it during a true crisis.
• Applying graduated pressure involves first seeking to understand a concept in a friendly, ultra-low-stakes environment. Then, when you understand the basics of the skill, you practice deploying it multiple times in conditions of increasing difficulty. Ultimately these conditions may mimic or even exceed the pressure of the real-life target environment in which you plan to perform.
• While it’s tempting to chart progress through graduated-pressure iterations by identifying the scenarios in which you succeed, the true magic of practice with graduated pressure comes from the way you encounter failures and setbacks during the repetitions.
• Instead, when you gradually increase the pressure in your learning environment, each iteration offers the opportunity to find a previously unseen weakness in your understanding or execution of the technique and the opportunity to address it.
• One of the best ways you can execute graduated-pressure training is through visualization practice, which is the active mental rehearsal of a process in order to improve subsequent real-world performance.
  • To start, close your eyes and visualize the step-by-step execution of a particular skill, such as the insertion of a central line. Don’t just visualize the critical points like inserting the needle, visualize every step from starting with opening the kit to finishing by placing the final dressing.

• To facilitate pressure training, you can take advantage of other situations that generate similar physiologic responses and mentally rehearse techniques when your sympathetic system is already revved up.
• For example, you could pause and visualize placing a central line at the end of a hard workout. Initially you could practice visualizing a process after mild exertion. Then, the harder your physical exertion, the more revved up your physiology would be and the higher the pressure you would be simulating.

05 TRAIN YOUR TIRED MOVES 

• Your “tired moves” are the techniques and protocols that function not only when you’re at full capacity, but when you or your team are exhausted. Overtraining these basic techniques produces a core structure that is resilient to stress and lays a foundation upon which more advanced practices can be based. Identifying which techniques are tired moves should involve leveraging both your personal experience and the aggregate analysis of others to determine what methods yield high success rates under extreme pressure.
• In moments like this, when you and your team must press on despite depleted reserves, you will rely not on your flashiest or most sophisticated tools, but on your “tired moves:” the skills, protocols, and techniques you have overtrained to the point that you could do them in your sleep. Put succinctly, your tired moves continue to work even when you are exhausted.
• First, personal practice involves attempting to perform different skills in high-pressure and high-fatigue situations and seeing for yourself what works and what does not.
  • you can run mental simulations in which you visualize performing a technique under varying scenarios and attempt to identify where further training is needed. Postmortem visualization, in which you start with the assumption that you have failed at a task and then work backward to visualize why, can be particularly useful in identifying tired moves.

• Second, aggregate analysis involves developing arsenals of tired moves by mining the experiences of groups that have deployed different techniques in a variety of real-life situations. As part of an after-action debrief, you can ask which protocols and techniques kept functioning (or even improved) when exhaustion set in, and which ones broke down or failed.

II HANDLING UNCERTAINTY AND IMPERFECTION 06 PRACTICE WABI-SABI

• Wabi-sabi embodies the concept that natural things are inherently imperfect, impermanent, and incomplete. Working with the wabi-sabi nature of the universe during an emergency helps you move past an unproductive and illogical need for perfect answers or permanent, unchanging solutions in order to focus on what actually works. Plans and teams built with wabi-sabi in mind are flexible and adaptive, resilient to failures of individual components, and more likely to succeed under pressure.
• When you need to perform during a crisis, a wabi-sabi mindset will help you focus on growth and improvement, accept uncertainty, and fluidly adapt to changing circumstances. By comparison, ignoring the wabi-sabi nature of life results in an inflexible approach that makes you more likely to underperform or even collapse when 
  • First, impermanence. Nothing in life, not even you nor I, is permanent. If you recognize and accept this impermanence, you can build flexible plans that adapt to changing needs and are resilient to stressors.
  • Second, imperfection. Embracing the idea that nothing is perfect during a crisis helps you maintain focus on growth, rather than comparing your response to some theoretical optimum.

• Wabi-sabi thinking teaches you that since nothing is perfect, perfection cannot and should not be your goal during a crisis. Instead, you can focus on performing at your absolute best and continuing to grow with each event you encounter. This might mean accepting a “good enough” solution you can actually accomplish, as opposed to being paralyzed while you look for the “perfect” solution.
• Finally, incompletion. You need to recognize that individuals and systems never stop growing and changing; nothing is ever complete. You will never have the complete answer on how to perform, since there is no total final answer. Growth, iteration, and experimentation should therefore be the norm for your teams, and you should welcome rather than resist changes in how you operate. You should always be willing to learn new ways to perform during a crisis, to update your mental models, and to seek feedback on how to do better.
• Holding this in mind helps you work to eliminate any trace of the “sacred way that things are done here” mentality, which can limit creative thinking and breed stagnation. Accepting that nothing is ever complete, you should work to develop a culture that consistently encourages new and better ways to respond to emergencies.
• Taking these three ideas together, practicing wabi-sabi means becoming a dedicated and lifelong student of your craft. You do not look for perfection, for completeness of knowledge, or for solutions that are “forever” answers. Instead, as you build your emergency mind, you focus on improving your performance and doing the best you can with what you have. You accept uncertainty and change, since they are omnipresent, and you devote yourself to growing with every crisis you encounter.

07 UNDERSTAND FALLIBILITY AND COGNITIVE BIAS 

• Cognitive biases reflect assumptions your brain makes below the level of conscious thought in order to simplify processing of the often-complex reality around you. These assumptions frequently have unintended consequences and can lead to systematic errors in thought and performance during a crisis. Exploring how cognitive biases subtly or overtly alter your seemingly logical efforts at making decisions is the first step in accounting for their effects. Every cognitive bias you are able to recognize is one you can attempt to adjust for while making decisions under pressure.
• Cognitive biases are assumptions about the reality around you that your brain makes below the level of your conscious control. These assumptions seem to exist to lighten the computational load of rapid and complex decision making.
• Anchoring bias describes the cognitive error you make when you tend to give more weight to information arriving early in a situation compared to information arriving later—regardless of the relative quality or relevance of that initial information.
  • A classic example of anchoring bias in emergency medicine is “triage bias,” where whatever the first impression you develop, or are given, about a patient tends to influence all subsequent providers seeing that patient.

• Confirmation bias is closely related to anchoring bias. It describes the cognitive error you make when you’re more likely to believe information that supports your current hypothesis or course of action and conversely more likely to discount information that suggests you might be incorrect. While logically you should weigh each new piece of information during a crisis on its own merits, confirmation bias suggests that you often subtly (or greatly) prefer coherence with your existing theory over absolute truth.
  • In essence, confirmation bias is about preferring to maintain one’s current mental model (that you are on the right path) over a new mental model (that you are lost or mistaken), even when there is no outside logical reason to do so. Uninterested observers who do not “own” a particular mental model do not feel a cost to changing their mind. Consequently, they are less likely to make confirmation errors compared to the person whose beliefs are being confirmed or disproven.

• Finally, recency bias describes the cognitive error you make when you give more weight to things that have happened recently simply because they are more easily available for mental recall.
• One of the most important decision-support tools we use in the emergency department is the “time out,” a structured pause immediately before the start of a crucial procedure. During the time out, all individuals who will be involved in the procedure gather together in the place where the procedure will be performed. They discuss the details of the planned procedure, confirm that the intended procedure matches the proposed underlying purpose, and discuss any expected deviations that might occur.

08 BECOME COMFORTABLE WITH UNCERTAINTY 

• Every emergency involves uncertainty, so learning to operate under uncertain conditions is crucial to an effective emergency response. While some types of uncertainty are obvious, other types are more subtle and require active awareness to identify. Your goal is not the elimination of uncertainty, but efficient functioning given uncertain conditions. Understanding this distinction will help you prioritize and fine tune your actions under varying degrees of uncertainty.
• firefighter and author Peter Leschak put it, “You must not merely tolerate uncertainty, you must savor it. Or you won’t last long.”
• A first step toward increasing your comfort with uncertainty is to explore the explicit and implicit ways in which uncertainty can come into play during a crisis. Explicit uncertainty describes an obvious knowledge gap, while implicit uncertainty is less obvious and requires conscious work to identify and address.
• Explicit uncertainty occurs when you know you lack understanding or are missing a particular piece of information. This uncertainty might involve details of the issue you’re facing, your available response options, the likely outcomes of particular actions, or combinations of all three.
  • First, recognize that getting rid of uncertainty is not always the goal; responding to the emergency is. You don’t always need to remove uncertainty to address the emergency. You just need to learn to be comfortable with the uncertainty you face.
  • Second, you can work to learn the physiological signs of uncertainty in your own body and mind. When faced with decisions in uncertain conditions, do you tense up? Do you tend to experience abdominal pain? Are you short with friends or coworkers? Sometimes what really is uncomfortable is not the uncertainty itself, but how you have conditioned your body to react to it.
  • To accomplish this, some providers use deep breathing techniques to counter uncertainty-induced shortness of breath. Others mentally walk through their bodies and visualize “unlocking” tight muscles. Personally, I take my own pulse at my right wrist, which helps me process my elevated heart rate as a sign of readiness, not of fear.
  • Learning to enjoy performing under uncertain conditions is a skill you must take responsibility for and consciously study and train. As mindfulness expert Jon Kabat-Zinn famously said, “You can’t stop the waves, but you can learn to surf.”

 

09 HARNESS THE WISDOM OF THE ROOM 

• As an individual, your understanding of what’s happening during an emergency is inherently limited to what you personally can observe and what data you are directly exposed to. Harnessing the wisdom of the room involves building a composite model that incorporates the understanding of every individual present. This yields a more complete and more powerful vision of the crisis than your limited personal view. Galvanizing a team to work on the same problem and empowering team members to share their visions are important leadership skills for teams performing under pressure
• First, as a team leader, your goal is to actively create a culture in which everyone in the room is clear on what test you’re taking and then to help everyone to take the test together. You must encourage and actively look for input from all team members, especially in teams with either implicit or explicit hierarchical structures.
• A first step in learning to harness the wisdom of the room is to ask yourself this question: “What might someone else see that I don’t?”
• A powerful question that can help you get past any initial reticence to consider an alternate viewpoint is: “What must this other person believe in order for that conclusion or action to be logical?” You can follow up by asking yourself what assumptions they might have made.

10 MAKE “PLAN B” PART OF THE PLAN 

• Operating during a crisis involves proactively preparing and training backup plans, since nothing goes according to your initial plan 100 percent of the time. Reframing the transition from Plan A to Plan B not as a failure but as an alternative pathway to success is a crucial part of improving individual and systems-level performance.
• preparing backup plans from the beginning—designing Plan B as part of the initial plan—generates robust systems that are much more likely to succeed during times of crisis. In other words, we need to view the move from Plan A to Plan B not as a failure, but as an opportunity to succeed using an alternate approach.
• At a systems level, embracing the importance of Plan B means designing protocols that are robust to errors of individual components, involve failsafe measures and backup plans, and anticipate that parts will wear out and need replacement.
• Importantly, designing systems that absolutely require a particular step or subprocess to function in a very specific way is asking for potential failures.

SUPPORTING CRITICAL DECISIONS 11 MOVE FROM A TO B TO C 

• To improve rapid and effective performance when mental processing is at a premium, emergency providers use the ABC algorithm to structure their initial approach to critical, undifferentiated patients. ABC—airway, then breathing, then circulation—leverages the hierarchical dependencies inherent in human physiology to direct effort first to upstream problems before downstream issues are addressed. In this way, problems are confronted in efficient order and available resources are leveraged and maximized.
• Each step—A, then B, then C—must function properly before the next step has a chance to work. Knowing this, you can cut through the uncertainty and focus your energy where it is most needed by looking first at the airway, then progressing from there. Importantly, the ABC algorithm is set up as a “do not pass go” strategy, meaning that if a problem is identified in one step, you do not move on to the next step until that problem is addressed.

12 LEARN TO ASK BETTER QUESTIONS 

• Your ability to respond effectively to a crisis is tied closely to the strength and quality of the questions you ask. Powerful questions will help you and your team move forward, while disempowering questions siphon energy and waste resources. The best questions during a crisis are present-focused and action-oriented. These questions are asked from within your sphere of influence and designed to address the most important decisions first.
• First, the questions you ask in an emergency need to be focused on the right period of time. During an active event, this typically means that your questions should be exclusively present- and future-focused.
• Second, effective questions during an emergency need to be focused within your locus of control, and they need to be action oriented. Questions focused on parts of the situation where you have no ability to act—things outside your control—can be wasteful or dangerous during a crisis.
• Questions that are high-quality in this domain therefore tend to follow the structure of, “What can I do right now with what I have to best move myself and my team forward?”
• Finally, the questions you ask during an emergency response should be tuned to address the most important, highest impact items first.

13 ELIMINATE UNNECESSARY OPPORTUNITIES FOR FAILURE 

• Unnecessary opportunities for failure are errors that you should be able to avoid or mitigate. Internal errors of this type occur when individuals make choices which unnecessarily diminish their ability to perform. External errors occur when systems or protocols contain potential points of failure that could easily have been addressed. Finding and eliminating these opportunities for failure is crucial to improving performance under pressure.
• You can start by considering a few of the most common critical moments in your environment—such as placing a breathing tube or transporting a severely ill patient—when the stakes are particularly high. Pick one of these moments, and perform a premortem evaluation or use negative visualization, looking for sources of potential failure.

14 DECIDE TO NOT DECIDE 

• The number of decisions you face during a crisis can easily become overwhelming. Thankfully, you don’t have to make every decision. Decisions that are easily reversible, have low impact, or do not address the primary forces at play can often be safely ignored or deferred. Rapidly identifying which decisions you do not need to make will help you focus energy on those that definitely need your attention.
• One crucial way to identify low-importance decisions is to look for equipoise, which refers to the situation where there is little to no difference in the expected outcomes between options in a decision.
• An important concept related to equipoise is “freerolling,” which applies to a situation in which such an asymmetry exists between the upside and downside of a certain choice that the decision becomes almost unnecessary.
• For example, one potential cause of cardiac arrest is hypoglycemia (low blood sugar), the treatment for which is administration of glucose (sugar). So, one plan of action during a cardiac arrest would be to test the patient’s blood glucose level and give extra glucose only if needed. However, if the patient’s glucose level is normal or even high, giving extra glucose during a cardiac arrest actually will not cause any adverse effects.
• Because there is no downside and considerable potential upside, the decision whether or not to give the glucose is—in this specific situation—a freeroll. As a result, you might choose to just give the glucose before the test result is back and move on to make other, more impactful decisions.

15 FIND THE RATE-LIMITING STEP 

• The rate-limiting step of a process is the slowest part of its execution. Identifying the rate-limiting step is critical to effective decision making under pressure, since this step acts as a choke on the speed of your overall progress. Often, the rate-limiting step is not the most technically or theoretically complex part of a process, but something mundane or easily overlooked. When the rate-limiting step cannot be easily determined, you should take this as a signal to invest more energy in understanding the details of the emergency you’re facing and your potential actions.
• A simple way to start working with the concept of finding the rate-limiting step during a crisis is to pause briefly, when it is safe to do so, and ask yourself what is preventing you from making progress. Once you have an idea of what needs to be accomplished, work backward from there to try to identify what slowest step in the chain is between where you are now and where you want to be.

IV BUILDING FROM CORE VALUES 16 COMMIT TO NEVER WASTE SUFFERING 

• No matter how skilled you become at performing under pressure, you cannot stop all suffering. You can, however, build and grow from that suffering. Committing to never wasting suffering means that you choose to leverage your experiences and those of your patients to improve yourself and your team and to learn to provide better care for your next patient. It means choosing to see suffering not as the end of a process, but as fuel for change and learning.
• Perhaps the single most important lesson is this: never waste suffering. Never waste the suffering your patients experience, and never waste your own.
• To waste suffering is to allow poor outcomes to happen without learning from them. It is to believe that nothing could be changed or improved at the end of a hard case, either internally or externally, to better prepare you and your team for tomorrow’s emergencies. In a sense, it is to be defeated, to give up.
• Structurally, wasting suffering tends to take two forms, either internalizing it or externalizing it. Both of these are equally futile responses and neither functions to push you or your team forward. Some individuals waste suffering by holding onto it too tightly or internalizing it too much.
• Alternatively, individuals might waste suffering by running away from it or over-externalizing it. In this case, instead of looking into what you could learn, you focus on everything outside your control that contributed to the recent poor outcome. You might blame equipment, teammates, environmental factors,
• Get curious about internal factors, such as how you mentally and physically respond to suffering, and external factors, like how you could have played better or understood deeper levels of the game. What does it feel like to commit to learning from the experience as opposed to running away from it?

17 HUMANS NOT ROBOTS 

• Being human during an emergency is not easy. In the short run, it can feel simpler to pretend to be a robot and ignore what you need, what you feel, and the residue that a crisis leaves with you. However, your humanity is not a weakness but a source of deep strength. Understanding how your body and mind prepare for and process stress and pressure will help you perform at your best, recover from difficult experiences, and return to strive again.
• Performing in the crucible of an emergency can be dehumanizing. Even with significant experience and skill in responding to emergencies, you can lose sight of your deeper self or start to view the individuals around you more as mannequins or actors in a play than as other humans. As you work through the extreme pressure and unfamiliar situations, it is often tempting to ignore internal signals like emotions and physical sensations, and to miss the depth, character, and humanity of people around you. 
• Honoring your humanity during an emergency involves several interconnected concepts. First, it means learning about fueling and taking care of your body and mind so you are capable and ready to respond to a crisis. Second, it means understanding that every person responds to an emergency differently, and that processing your personal response is part of your job. Third and finally, it means learning to recognize and address the often painfully deep stress that encountering trauma and crisis can place on you, your teammates, and the individuals you serve.
• As someone who is training to perform under the pressure of an emergency situation, you are an athlete, and you need to treat yourself like one. Sleep and hydration are crucially important factors affecting human performance, as is the balance between energy intake and the mental and physical outputs required to perform your craft.
• A useful way to understand and address what happens after you go through an emergency is the concept of “residue.” Put simply, difficult experiences leave residue that can build up and block or choke your system if you don’t address it, just like the residue in a water pipe can build up and impede flow.
• Personally, I find that daily exercise, consciously training gratitude, and engaging in meditation (or some sort of reflection practice) make enormous differences in my ability to be a good emergency physician.

18 START FROM FIRST PRINCIPLES 

• Your actions under pressure should at all times reflect your deepest values. The more clearly you understand these values, the easier it will be to make sure your choices align with who you and your team are and want to be. You must explore your ethical frameworks ahead of time, before a crisis. You can test these frameworks the same way you test your technical skills, by applying graduated pressure.
• A fundamental principle in performing under pressure is that your actions should at all times reflect your deepest values. A corollary is that the better you personally understand your moral principles—the more clarity you have about your core beliefs—the more capable you’ll be of acting in tune with these principles.
• Without a clearly defined ethical framework on which to base your decisions, actions in these complex situations may be inconsistent, inefficient, or subject to potential bias. With a well-developed ethical framework, you can be more certain you are making decisions that do align with your deepest values, even in high-pressure moments.

19 FAVOR PRAXIS OVER THEORY 

• Acting during a crisis requires operating from the “solution space” created by the overlap of what is theoretically best practice and what is actually possible at the moment of a particular emergency. Praxis—the application of abstract knowledge to real life—is the realm of the emergency mind. Learning to identify what will actually work at the cutting edge of the crisis is a key skill in performing under pressure.
• While elegance is always appreciated, functionality and practicality are generally the highest design virtues in an emergency. Praxis— the application of the ideal to real life—beats theory when lives are on the line. No matter how “perfect” a solution to a problem may appear on paper, if it’s impossible to implement when and where an emergency is happening, it is not the correct response.

20 RAPIDLY ACCEPT REALITY 

• The faster you’re able to process and accept the reality of a situation, the better you’ll be able to perform. Energy spent denying, complaining, or wishing things were different is energy you cannot use to respond to a crisis. You must be vigilant to recognize when a situation has changed and adapt to it. Importantly, rapidly accepting reality does NOT mean that you accept or agree with what is happening, just that you adapt to it in order to do your best work.
• During the battle of Thermopylae in 480 BCE, an alliance of Greek soldiers defended their homes against an overwhelmingly larger Persian force. At one point, the arrows of the Persian army were said to be so numerous that they would block out the sun. Hearing this report, a Spartan warrior named Dienekes is said to have responded “In umbra igitur pugnabimus,” which translates roughly as, “Well then, won’t it be nice to fight in the shade?”
• Dienekes’ response holds a critical lesson for building your emergency mind. You don’t choose the details of the emergencies that come your way—where or when they happen, or the type of challenges they bring. You certainly don’t choose the number of arrows an opposing army sends your way. What you do choose, however, is how you adapt to, and accept, the situation.
• Another reason you might not succeed at rapidly accepting a new reality is that you just don’t want to. Often times, the situations you face when responding to emergencies are outrageously rough. They can be mentally, physically, or emotionally draining, and often are all three. Sometimes the situations are so extreme that they threaten to overwhelm you; not accepting the reality you see can feel psychologically safer than adapting to it.
• You do not condone what happened, you are not okay with it, but you will accept it and move forward because that child needs you.
• Personally, when I face the arrows of uncertain and challenging circumstances—when I am trying hard to accept the reality of a difficult situation—channeling Dienekes’ dark humor helps me recommit to fighting in the shade. As the Stoic philosopher and Roman emperor Marcus Aurelius is reported to have said, “Death smiles at us all; all we can do is smile back.”
• When performing under pressure, you must always be vigilant and proactive, continually asking yourself if the situation you are addressing has changed. Are there new arrows heading your way? Actively seeking disconfirming evidence—asking yourself and others what you are missing that could lead to a different conclusion— is one way to overcome confirmation bias and increase the chances of recognizing a shift in circumstances.
• As Gonzales says, again about survivors of serious accidents, “To the survivor’s mind, all cues are important. They carry information. So, a survivor expects the world to keep changing and keeps his senses always tuned to: What’s up? The survivor is continuously adapting.”

V BALANCING COMPETING FORCES 21 SEE THE FOREST AND THE LEAF 

• Optimizing your performance during emergencies requires balancing attention between a tight focus on individual details (the leaves) and a broad focus on the whole field (the forest). Some circumstances will require your focus to be either completely tight or completely broad. As an intelligent default, your attention should be skewed toward zoomed-in, but not completely. When you tell your teammates where your focus is directed and why, they can better understand your priorities and efficiently coordinate efforts.
• During routine operations in the high-stakes environment of an emergency department, the best default is typically skewed somewhat more toward “zoomed in” than “zoomed out.” You generally want the majority of your focus to be on the patient in front of you, with some attention devoted to scanning for threats or critical signals throughout the rest of your department. Importantly, this also allows you to pivot quickly if a sicker patient arrives unexpectedly or help is rapidly needed elsewhere.
• Communication and delegation are key, and cognitively offloading some of your thinking to skilled team members helps you deploy your focus where you need it the most.

22 FIND YOUR LOCUS OF CONTROL 

• Clearly identifying what you do and do not control helps you focus your resources and attention where they can make the most difference. Energy spent chasing things you do not control is energy you cannot bring to bear on a crisis. Ask yourself what you can accomplish right now to make this situation better with what you have. Concentrating on this question before, during, and after a crisis will help you eliminate performance anxiety, recognize where you can make the greatest difference, and clarify where you should focus your future training.
• The Stoic philosopher Epictetus said, “Things in our control are opinion, pursuit, desire, aversion, and, in a word, whatever are our own actions. Things not in our control are body, property, reputation, command, and, in one word, whatever are not our own actions.” Put another way, there are two types of things in the universe—the relatively small set of things over which you have control, and the much, much larger set of things you do not control.
• The best way to practice finding your locus of control is to jump in and ask what you can do right now to make a situation better. If that question feels too difficult or complex, start by looking for three things that you control during a situation. If three is too many, start by identifying one single thing that you control during a crisis.

23 TREAT THE INDIVIDUAL AND THE FIELD 

• Since emergencies often require deploying scarce resources across multiple patients with different needs, caring for an individual must be done within the broader context of the overall mission. Sometimes, this means the needs of an individual must be subjugated to the needs of the set of patients you are treating. Having an up-to-date mental model of the whole field is necessary to navigate this tension.
• you need to actively seek out ways to contextualize your individual actions within the broader scope of your mission, and update your priorities as the situations you face continue to change.

24 COMBINE ACTION AND ANALYSIS 

• Your emergency mind includes a “fast gear” that prioritizes immediate action in the face of uncertainty and a “slow gear” that prioritizes deep investigation and thoughtful experimentation. Knowing when you are forced to act immediately and when you have time to step back and analyze a situation comes with experience and training. At more junior levels, you should prioritize action first and analysis second during a crisis.
• To perform successfully under pressure during an emergency, you need to develop two distinct modes of behavior. The first mode is fast, action-focused, and devoted to addressing a particular situation. It makes use of whatever knowledge and tools are available at the moment and generally seeks to address a specific goal, like helping a choking patient breathe.
• The second mode is more careful and exploratory. It is devoted to seeking out the best possible solution to a problem and involves gathering data, comparing options, and planning future courses of action. Generally, this second mode seeks to balance multiple different priorities such as diagnosing a patient’s illness while being efficient in resource utilization.

25 USE ALGORITHMIC AND CREATIVE THINKING 

• Algorithmic thinking is linear, follows predetermined paths, and can be used at a variety of skill and knowledge levels. Creative thinking is non-linear and relies on taking steps and leaps between often disparate areas of knowledge to form uniquely tailored solutions. Each form of problem solving has its strengths and weakness in different situations, and wiring your brain to perform involves leveraging both.
• Algorithms are sets of instructions designed to be executed in a particular way to solve a specific type of problem. Algorithmic thinking relies on using predefined approaches or decision-support tools to arrive at a solution or dictate the next appropriate action. This type of thinking is linear in that it proceeds stepwise along a known path. It is predetermined, as the path of analysis was laid out ahead of time.
• By comparison, creative or free-form thinking follows no predetermined rules and attempts to derive a unique, one-off solution for a specific problem. Where algorithmic thinking is linear, creative thinking is unstructured and can proceed dynamically between different options. Often, it involves small steps and close iterations of possibilities. In the example above, this could be something like continuing to attempt to suction the blockage but using a different type of suction device. Other times, free-form thinking makes large leaps in logic and reasoning to present a totally novel idea, like moving the blockage down instead of up.
• Comparing these two types of thinking, emergency physician Dana Sajed, MD, describes algorithmic thinking to be like musical scales and chord progressions, and creative thinking to be like improvisational jazz.
• algorithmic thinking is easier to deploy when you’re exhausted, hungry, or cognitively overloaded; algorithms are the “tired moves”
• Second, algorithms can only use the types of data that were known when the algorithm was developed can only generate a conclusion based on that data. By comparison, creative thinking is unbounded both in its inputs and solutions. Even when it follows some core rules, like the logic underlying the art of a jazz solo, it is more likely than algorithmic thinking to arrive at unique solutions.
• Third, since creative thinking often relies on generating connections between seemingly disparate points of information, the deeper your fund of knowledge, the stronger the tool can be for you. While the “fresh eyes” of a novice practitioner do often yield novel results, domain experts are at a distinct advantage when utilizing creative thinking, as they have both a deeper and a broader array of experiences to draw on.
• Algorithmic thinking, on the other hand, is largely indifferent to your level of expertise. As long as you’re able to understand and execute the individual steps of an algorithm, your level of your training is typically not a factor in its function.
• The act of developing expertise in an area and transitioning decision making from conscious to automatic circuits is often referred to as “schema generation,” or “chunking.”

The ONE Thing. Their question is, “What’s the ONE Thing I can do such that by doing it everything else will be easier or unnecessary?”