Like everyone I know in EM, I was never given psychological performance skills to maximize my response in crisis situations. I just assumed, and was led to believe by my teachers, that through some kind of desensitization, I would just get better. Over decades of practice I did improve, but recent interactions I have had with military personnel have now convinced me that we can train to do better by directly confronting the gorilla in the room and addressing the psychological aspects of procedural performance.

I am so convinced of this that I have added a psychologist, Michael Asken, PhD, my co-author on this article, to the faculty of my airway course in Baltimore. I now view every component of airway management with a different perspective. I think about how stress conspires to make us fail and how it must be handled at each step in the process.

Fear is like fire. It can cook for you. It can heat your house. Or it can burn you down.
—Cus D’Amato, boxing manager, trainer

Adrenaline increases our heart rate, dilates our blood vessels, and widens our pupils; it gets us ready for the increased physical demands of a fight-or-flight situation. Excess adrenaline, however, becomes very dangerous, especially when we are required to perform complex tasks (as opposed to just running away from a predator). In the procedural performance situation, the mismatch between the perceived demands of a task and one’s perceived abilities creates “performance stress.” When the mismatch is dramatic, the adrenal dump that occurs becomes detrimental. Above 115 heartbeats per minute, fine motor control is compromised. Above 145, gross motor control is affected. Time perception gets altered. Our ability to appreciate external cues (ie, listening, accurately observing the situation) becomes limited. Frozen by the stress, operators become “stuck on stupid,” repeating the same response over and over (even though it’s not working). The Brits jokingly refer to this as “wearing brown trousers” because in superstressful situations bowel control is compromised. Tactical operators emphasize the importance of the “battle crap” before beginning a mission. At a recent conference in Australia, I heard an EM doc refer to using bike clips with their brown trousers—now that’s stressed!

Above 115 heartbeats per minute, fine motor control is compromised. Above 145, gross motor control is affected.

While it was once believed that crisis functioning or mental toughness (the right stuff) was something that you either had or did not have, we now know this is not the case. The military, professional and Olympic athletes, and police agencies have all recognized this and created psychological training programs to maximize performance in high-stress and life-threatening situations. Emergency medicine has lagged far behind in this critical area.