 So now that we've talked about all this what we got to talk about is your internal state to be able to perform an Udalloop because what goes on around you compares little to what goes on inside of you and having control of what's going on Inside of you is what's going to make you a good practitioner of the Udalloop So you got to check yourself before you wreck yourself because Udalloop's work when you're calmly stimulated, okay? They jam up when you become too amped up and too excited And they depend upon metacognition and working memory and freaking out kills both of those like that so In the lecture that I spoke about at the beginning Scott Weingart MD and Michael Lauria came up with this mnemonic For how to keep your internal state so that you are in the appropriate zone for performing optimally under stress And they called it beat the stress foolish padawan and Those each stand for something and it stands for breathe talk see focus and posture, okay? So breathe we're talking about tactical breathing or box breathing, okay, and it's as simple as this You breathe in over a four-second count You hold breath for four seconds You let it out for four seconds and you hold expiration for four seconds and you repeat that four times When you do that that calms you that slows your heart rate that blunts your sympathetic drive And it brings you down to where you're more optimal in your functioning under stress This simple measure by itself has decreased in doctor nation washout in military special forces training by a third Just that alone has decreased the number of seals that go up ring the bell and say I quit What we're doing when we're doing this is this is out of a book by lieutenant colonel david grossman called on combat and He shows this physiologic response, and I know this is hard to read But basically as your heart rate goes up you get more and more undesirable Physiologic reactions so when your heart rate is going from 90 to 120 your fine motor skills start to diminish Which are complex and gross motor skills are starting to ramp up some but between 120 and 150 complex motor skills Start to break down you got to keep control of that and then between 150 and 175 Your cognitive processing deteriorates you get tunnel vision like I described when I passed out on the floor Loss of depth perception everything that you need to perform in a high stress situation starts to degrade and when you get up here This is unintentional fight-or-flight response. This is Soiling yourself Submissive behavior all of those things kick in an extreme stress. Is anyone in the room here ever been scared enough where they actually Pissed or craft themselves Good you have lived okay? The thing to keep in mind with this heart rate is this is hormonal and fear induced heart rate increases It's not necessarily the same thing when your heart rate is increased by exercise So you can get up into those higher heart rates with exercise and not have the same degrading response The other thing is ramping up happens really quickly ramping down into a more acceptable range can take as long as three minutes and If you rest longer than three minutes, you can have what's called parasympathetic Parasympathetic backlash and if you've ever wondered how soldiers can sleep in a foxhole with mortars going off all around them That's parasympathetic backlash Okay Talk and what so beat the stress bullshit. This is talk T That's self-talk you talk yourself up. You got to talk to yourself. Why you're doing this You got to think about your thinking so you got to say you can do this You've got to consciously enact metacognition say what's going on here? What's going on around me and then ask disconcerting questions check yourself for common thinking fallacies Now Eric Daniel is going to talk to you guys about thinking fallacies tomorrow So pay very close attention Because whenever you're in a stressful situation, it's very important that you ask these disconcerting questions of yourself See that means to visualize That means you picture your desired outcomes you picture potential problems and what your response to them will be and Vivid visualization before the fact is just as good as doing the real thing Every time I'm driving in for an ER shift. I do three things in as much vivid detail as I can I Visualize performing an emergency department for economy and all the steps of it like you saw at the beginning with a Seabooth at UCLA I picture performing a cricothyrodomy which is getting into the wind pipe when you can't get an airway by another mechanism And I picture doing a postmortem C-section Those are two or three of the biggest gnarliest procedures that I might have to be faced with and I run through those from beginning To end on my drive into work every time I go so that when the hammer drops I don't hesitate because hesitation kills in those situations. You got to act fast Focus focus is a key word that you're going to have for yourself to put yourself in that state but you got to use that keyword in combination with Meditation exercises that you perform at home You got to become Confident at zen like meditation. I use a specific hand gesture, which is two fingers on my thumb When I'm meditating and getting to that state of clarity So that when all of a sudden The back doors crash open and a parent's carrying a dead child in their hand I stand up take a deep breath put my fingers together And if you're practicing up at it, you will go there almost immediately and The last one posture Okay, when you are in a stressful situation assume a dominant posture It increases your testosterone by a third and suppresses your cortisol by one-third Very important in the stressful situation. You want to be open and expansive You don't want to be curled up and taking up less space. You don't want to be timid. I will defer you I'm not a big fan of Ted talks. I think it's a bunch of people that think they're really smart that Probably couldn't fix a toaster sitting in the office You know just toppling theories left and right, but this one is exceptional by Amy Cuddy on the power of posture I recommend that everyone just hit YouTube and or Google and go check it out It is a very powerful talk about posture one thing I notice amongst my colleagues Whenever we have to call a consultant in and bring them in on a case Sometimes it's like selling refrigerators to Eskimos and the people that are all curled up and acting timid while they're talking on the phone Always get shit People that sit up tall Expansive have their feet up on the desk while they're talking those people always get results posture is important Another and that brings us to dr. Doug McGuff Let's bring it home First time I remember having it We were At the end of shift and I was coming on and we were talking about the patients the ambulance rolled between us with this well-dressed middle-class looking guy curled up on the stretcher moaning and groaning and Acting dramatic and I thought now brother That guy rolled between us and my attending said keep a close eye on that guy. He's got mesenteric ischemia Meaning one of the arteries to his bowels is blocked and he's dying I'm like shit How do you do that? Well two and a half hours later after multiple testing and an angiogram of the gut. He was right Okay, and I realized because this guy was well-dressed and he was acting dramatic I made an assumption about him and I latched on to that for normal C bias. I See it with nurses. They'll bring back a patient That and if you ever show up in an ER kind of look a little scrungy my friends Don't wear your clean underwear because the more normal you look the more Normalcy bias will kick in for the people taking care of you We can believe that some derelict that we pulled out of the gutter is going down the drain But you come in, you know with your you know khakis on and a nice press shirt and you're doubled over. It's kind of like Whatever Because your brain seeks normalcy. I see them bring someone that's actively dying and put them in a non Acute room and if you're seeing a really sick patient in a room that's designated for not sick people Your brain will run to normalcy bias and you have to protect against that and then finally We want to be able to bend the curve and what we're looking at here on this curve is You have performance on the y-axis and heart rate on the x-axis and what you'll see is as heart rate goes up You reach this optimal performance zone here at the top Okay, if you get too stressed out You start to go into that realm where everything starts to go to pot Well, there is a way of performing stress inoculation to bend that curve So you go from condition red instead of going into condition black You just extend condition red out further Loops and think in terms of breathing self-talk actually do all those things