 I'm Anthony Johnson, founder of the 21 Convention and CEO of 21 Studios. You're about to watch a video from a 21 Convention live event. Before you do, I want to encourage you to join our free newsletter. All you've got to do to join the newsletter is click the big box right around here and you'll be all set. And by joining the newsletter, you're going to get a free gift. We're always updating it so it could be exclusive videos not on YouTube or it could be a free e-book, things like that. Always an awesome gift, always a free newsletter. Thanks and enjoy the video. Happening in the 21 Convention, Tampa, Florida. Right now, we are about to bring on stage somebody who wrote an amazing book, which is called Body by Science. And it's changed many people's lives, including many of the viewers out there. He has one of the most popular speeches at the 21 Convention, an amazing wealth of knowledge. BodybyScience.net is one of the sites. Dr. McGuff is another. And that brings us to Dr. Doug McGuff. Let's bring it home. And great to see you. Thanks for having me. Hey guys, thanks for having me. My previous visits here have been all about high intensity training and paleo diet and biochemistry and things of that nature. Anthony asked me to come back and talk again. I just couldn't stand the thought of giving you guys another high intensity training lecture. And there's actually a wealth of folks here. That are going to be offering that. And the nice thing about teaching some of this stuff, is that all of a sudden you realize people are exceeding your knowledge. And I think that you may get better exposure to that. So I decided this time, what else do I know that I can talk to these guys about? I started to think, well, I talk a lot about what's gone wrong in medicine and how stressful it is. And I thought, well, maybe I can teach something about operating in high stress environments. And this was further triggered by I was doing some continuing medical education. And I was following this podcast called Imcrit. It's an emergency medicine critical care. And it's run by a fellow named Scott Weingart. He's a physician that specializes in critical care. And he gave an interview with a fellow named Michael Aurea, who was a ex-air force para rescue jumper or PJ, which is like some really bad dudes. And they were talking about the cognitive skills of functioning in a high stress environment. And I started to realize I really do a lot of this stuff, but I've never really articulated it to anyone. So that's what this talk is going to be about today. Say what? Am I holding this upside down backwards? All right, so when we're talking about operating in high stress environments, the thing we got to see is that emergency medicine is a uniquely stressful occupation. I'm trying to establish that I have some credibility to talk about this with you. And to give you an idea of why that is so is emergency medicine is a really unique specialty. If we take all of medicine and we divide all the different specialties up into slices of a pie, what emergency medicine is, is the very center of the pie or that little hole where all the gooey, good, juicy stuff is. And you have a little circle that goes right around the center of that pie. And it's about the first hour to two hours of every specialty with the worst possible things that can happen in each individual specialty. And we have to know the worst possible things that can happen in each individual specialty all the way up to the limits of our knowledge and then the next step. Because we've got to know how to transition care of these people into the next step. So in any given specialty, the specialist is going to encounter the very worst and most stressful aspect of their specialty only in extraordinarily rare circumstances. But because of our locus of operation, if something went bad during the birthing of scholars' babies, like he said, it would come to us because that is our job. We are at the center of that pie. We see the highest acuity and the highest severity of illness by design. But something else has happened is emergency medicine, as it was originally conceived, was somewhat like a firehouse. Because only if you had that high level of acuity or severity were you really even allowed through the door. In the 60s and 70s, a lot of emergency departments had a doorbell. And the nurse would come there and, like, how sick are you as your pancreas hanging out? Or isn't it kind of criteria? But that was different at the university hospitals. Because in 1946, the government passed a law called the Hill Burton Act. And it was a law that lasted 40 years. And basically what happened with the Hill Burton Act is insurance companies were not wanting to care for the poor and the elderly because they were too expensive and they were costing them money. And in cahoots with the government, they decided the government's going to fund graduate medical education, all these internships and residencies. At these big teaching hospitals in the inner cities. Well, in exchange for that funding, they had to agree to take all comers. So the emergency departments in these big urban teaching centers became just these boiling pots of stress. They were constantly overrun with the sickest and worst imaginable patients you could ever hope for. Well, it was a 40-year law that ran out. From 1946, ran out in 1986. In 1986, something magical happened and that magical thing is called mtala, the emergency medical treatment and active labor act of 1986, which says any emergency department anywhere must see anyone that presents regardless of their ability or intention of paying. And you could not turn anyone away without providing emergency medical stabilization. And effectively what that did was that took the environment of the urban level one trauma center, teaching center, emergency department and made that environment spread into every ER across the country. So now on any given day, you can be walking and it'll be absolutely beautiful outside. You walk through the sliding double glass doors of almost any emergency department in this nation and you will drop into the pits of hell. You will literally, it is unbelievable when you walk in there what the difference is in just one second from walking through that door. You have been thrown into an environment that is just unbelievably stressful. Combined with that stress is the fact that because we now can see all comers, we're now the safety net. For all things medically emergent, urgent, non-emergent and non-medical, you can have a fight with your girlfriend and have a hissy fit in an estrogen storm and you can decide to come see me and that's the way it is. So mixed in to this whole problem of these really, really sick patients is a lot of other patients that are not really sick. But you are now dealt the problem of this needle in the haystack decision making and it's basically just infusing a lot of chaos into the system. There's also a lot of artificial constructs government regulation, how you can play the game, what's allowed, what's not allowed, electronic medical records, which are a government boondoggle of the most inefficient, DOS based, nesting dolls of folders, nightmare you could ever imagine for trying to keep track of what's going on with your patient. And this sort of pattern is found in many other professions and situations. It can be found in people that are in law enforcement. It's found in the military. Now the military who was originally supposed to be defending us against foreign invaders or against, you know, combatants overseas are now doing humanitarian missions. Now the army's flying out to process Ebola patients in Liberia. So you're doing things that you weren't even really supposed to do with expectations that are really high and severe punishments for when you screw up. And that creates this uniquely stressful environment that I'm talking about that you have to really develop some skills to function in. And the neat thing though is these skills are transferable to other situations and that's what I want to teach you. I don't want to teach you guys how to be an emergency doctor. I want to teach you how to function in the world when the shit hits the fan, okay. This is just a quick clip of, okay. So very dramatic obviously, a little bit amped up. But there's important elements of this to know. First is when I was in those guys position, that's a quarter of a century ago. That's how long I've been doing this. The other thing that kind of encapsulates what I'm talking about is this inability to overcome a normal sea bias. It's like first time I went into the sea booth I couldn't believe what was going on here. I couldn't orient myself. It was very chaotic and I couldn't understand what it was. The second thing was is the young lady that said I wanted to be that person, that calm, that in charge. And that really is a skill. And what you don't know about that guy is when you're watching him is he may have worked four night shifts in a row, been home to try to sleep. And then he has a two and a four year old that both have a vomiting virus. And he may have been up all night and then come in and have to do that sort of stuff. Life goes on in the context of having to operate in that kind of environment. The third thing just in context to current events that I want y'all to think about is remember the scene from the waiting room? Everyone is just going eight crazy about the fact that an Ebola patient was missed in a Dallas emergency department. Remember the view of that waiting room. Which one of those patients was your Ebola patient? And you remember that little thing that are scrolling down on the computer screen and had all those different colored things? That's the electronic medical record. And it says lab rad, NA, obs pen. All those things are data elements on any given patient. They're not visible to you. So when flu season hits, you have an emergency department waiting room that looks like that. And you have an electronic medical record that is this DOS-based monstrosity of nesting dolls of folders to get to any data points. It is not a surprise that any Ebola patient slipped through the cracks in the Dallas emergency department. Okay, that was created by this artificial construct that we're having to deal with. Here's a different view from Oakland. The constant in the morning, those people walking down the sidewalk, when you're the dock on duty and you just see the bus literally, the public bus unload and they're just flooding in. And knowing that you gotta kind of take the air traffic control aspect of this and stay on top of the wave, mounts a lot of tension. And that can be hard to understand, but this morning I took my kids down to breakfast. We ate breakfast. There were three people seated at the table. We were the fourth table. And just the fact that we came there crossed the waitresses' stretch threshold. There's nothing at stake, it's just breakfast, but just having to accomplish a certain number of tasks in a certain amount of time caused her enormous stress. And there are ways of dealing with that. So what's my other unique qualification? Well, it's this. I wouldn't cut out for this, at all. I'm an inherently anxious person. I have a fragile psyche and I'm overly empathetic. I saw someone give a course on self-defense once and they said, whenever you're watching a movie and there's a fight scene, regardless of whether it's the good guy or the bad guy that's dominating in the fight scene, you should always try to identify with a person that's given the beating and not the person that's receiving the beating. I'm not that guy. I become overly empathetic. Even when I was in middle school, I remember some kid got sick at school and puked. It freaked me out so bad, I empathized with it so bad, I became incredibly fearful of becoming sick and vomiting to the point that I made myself sick any time that I thought about it. It was insane. My first ER experience, when I was in college, I thought, I wanna go to medical school. This is what I wanna do. And part of that was you had to demonstrate some curiosity about the medical field. So I volunteered at the University of Texas Health Science Center emergency department. And my very first experience as a volunteer, I was useless. So they did what they could do with a useless volunteer. We had this little Vietnamese guy, spoke no English, who was schizophrenic, who was being held to be admitted to the psychiatry unit, but he's being held in the ER and he needed a sitter. So they sat me down in a chair and this little Vietnamese guy was sitting there and talking to himself and he smiled at me and I smiled at him and he opened his mouth, stuck his tongue out and he had a single edge razor. And I froze, he just took it out and I thought, oh my God, he's gonna kill me. And then he took the single edge razor and he shoved it in full depth into his wrist. And then he went vertically with the full depth of the razor up like this. And I remember feeling the sensation of ants crawling on my forehead and my vision was like I was looking through a paper towel roll and then there was nothing. And when I came to, there was this huge ruckus of people stepping over me as they were wrestling with this guy and trying to get in control and they sent me home. It was the most humiliating experience and it clearly, and I mean it was even said to me, you are not cut out for this, don't even think about it. Medical school was a similar experience. It was the most miserable four years of my life. I got into medical school by being the ultimate anal retin of study year. I studied from dusk till dawn. I always made sure that I was gonna get an A on every test so I could get into medical school, which I did. But once I got into the medical school and the volume of the material was so great, I didn't know how to scale back and quantitate my effort. So the way I compensated for that was I woke up at five in the morning, I studied until one in the morning for two solid years because it was the only way I knew how to do it. I did not know how to calibrate getting a B or getting a C or any of that. When I got to my clinical years, I knew I would be seeing sick people. I had no conception of how sick people could actually be and how overwhelming that was. And you had this sense of you had to manage or fix something that was completely unmanageable. So, I would vomit frequently every morning before going in for rounds, if not vomit diarrhea at night when I would finally get to sleep. And these were on rotations where you have every other night calls. So you're awake for 36 hours, you get to sleep for six or seven hours and then you wake and do 36 hours again over and over. But when I would sleep, I would have night sweats and soak the bed sheets. That's how terrified I was through the whole process. So I clearly was not cut out for this but I wanted to not feel fearful anymore. So why did I choose emergency medicine if all of this is true? Well, I was tired of being scared. I didn't wanna be afraid of anything. I was tired of that feeling of not knowing what to do or not being able to deal. And I wanted to be in control of the chaos or I at least wanted to contribute to the chaos in a way that put me as part of the process rather than someone being acted upon and I didn't wanna be afraid of anything in any specialty. So how'd I do this? Well, in a word stress and oculation, I sucked it up. I faced my worst fears by provoking them and I lived through it. When I was in middle school, I told you about the whole fear of throwing up kind of thing. I finally got to where I was just sick of this. I was just so fearful I was gonna catch a bug and start vomiting and then it would be so traumatic. I ate a really big meal. I drank a lot of milk. I went out to the track and I ran as fast as I could as long as I could until I puked and then I got over it. Literally in that moment got over it. Sometimes you just gotta find an alternative and then fake it. You gotta act like the guy that you wanna be and just fake it until you make it. And then the lastly is get some skills. Read books, find role models, seek out a mentor, get educated and study like hell. Get mastery of something so that you can be confident in a situation. And in the medical aspect, emergency medicine was facing my worst fear. Throughout medical school I did see circumstances where different specialists, when they were actually encountered with those center of the pie scenarios that we had talked about earlier, literally came unglued. I could see it happen. And I did not ever wanna be that. And I didn't wanna be that under any circumstance in medicine and that's why I chose the specialty that I did. Hi, hope you're enjoying your videos so far. My name is Anthony Johnson and I'm the founder of the 21th Convention and CEO of 21 Studios. If you're serious about improving your life, you need to attend a live event. To learn more about attending a live event, all you gotta do is click the box right about here and it'll be all set. Thanks, enjoy the rest of your video. Given my interests in high intensity strength training, one would think that I would naturally gravitate towards orthopedics or physical medicine, but the whole experience really drove me to choose what I did. And when I did choose what I did, I read a book by Samuel Shim. It's called The House of God. And there are rules in this book. There's 10 rules of the House of God. And there were some rules in here that really made an impact on me. And the House of God rule number three was this. At cardiac arrest, the first procedure is to take your own pulse. Why that is will become evident as we move through in this talk. And the number four rule was the patient is the one with the disease. You had to take empathy and turn that into sympathy. You had to have enough distance to where this wasn't happening to you personally, but have the sympathy so that you could actually do something about it. You had to get that distance. And I came to realize that when I went to work every day, that I may be faced with something and a patient may die, but I wasn't gonna die. I still be alive at the end of the day, even if my patient died. And what I came to also realize is that the gnarliest and scariest situations, cardiac arrest, traumatic cardiac arrest, like what you saw here, is not really the most stressful thing because you can't kill a dead person. You can't make them worse. Even a critically ill person, the interventions that you have to take on a critically ill person are extraordinarily simple and they make a huge, huge difference. So the pressure is off. You can't make a really badly sick person or a dead person worse. So that gave me a little perspective. I was kind of able to move on and do something. And then I got the skills. I actually did an emergency medicine residency. I repeated that three step process with each new skill and I had incredible teachers and role models who knew how to incrementally increase my stress dose so I was not overwhelmed but that I could grow step by step to the point where in the second half of the second year of your residency, you were allowed to moonlight, where you really were on your own. And I moonlit at this place called White River Medical Center in Batesville, Arkansas. And it was like this funnel or vortex of badness. It was the most high-acuity, to this day it is the most high-acuity emergency room I've ever worked in. And just feeling ready to go into that place and then actually surviving that place without the comfort of an attending physician standing behind me really launched my growth to a new level. So once you're there, once you're comfortable with doing all this, you gotta go to the next level, which are some cognitive techniques. And I list these, I made these up. The Stoics approach uncover the artificial construct and the context diffuses the stress. So the Stoics approach is this, is say, okay, if all the bad crap that could happen to me in this world, what's the worst? The worst is you could die. And as an emergency physician, you start to realize we're all gonna die on a day. You will wake up in the morning but you won't see the next one. You were gonna die on a given day. And if we all knew what that day was, I'm not sure how it would affect us. But the knowledge you were gonna die on a day and the death rate never, ever changes. It's always one per customer. And once you wrap your head around that and view all of your stressors in that context, everything else just kind of falls away. The other is you have to realize is that a lot of the stress is an artificial construct. The requirement to see everyone that's flooding at you. The requirement to document this, that, and the other thing on a computer system that's foisted upon you that doesn't work. When it really does matter, you gotta realize what doesn't matter that people are trying to make you think does matter and let it go. And once you have that context, you diffuse the stress. Once the stress is diffused, then you can go in to the real cool stuff. Has anyone ever heard of Colonel John Boyd? Yes, yes. Okay, they called him 42nd Boyd. John Boyd was a fighter pilot and he was instrumental in the development of the F-15 and F-16 fighter jets. And they called him 42nd Boyd because in any training drill or any combat situation, he could start with someone having weapons lock on him. And in less than 40 seconds, 100% of the time, he would have weapons lock on his opponent. And he taught fighter pilots this technique. And when I first saw this, I thought, this is a bunch of crap. It looks like something out of, you know, a business meeting that you have to go to with all these flow charts and stuff. It looks ridiculous. But discussing a little bit will make you understand how this actually works. And it is very important because it talks to us about how our human minds work. So he called this an OODA loop. An OODA stands for Observe, Orient, Decide, and Act. Okay? So when you're thrust into a stressful situation, and that could be anything. That could be walking into work at the ER. It could be the pipes busted and your kitchen's flooding. I mean, it could be any different sort of stressful event. The first thing that happens is that you observe. There's unfolding circumstances. There's outside information. There's interaction with your environment. And that's something that just happens to us. Okay? And any human does this. The problem is, is almost every human stops right there. Okay? This, right there, the observations is thinking. Okay? That's cognition. What happens next is we feed forward into Orient. And Orient is where your mind really comes in. That's called metacognition. And this is something that objectivist epistemology talks about, is that the human animal is the only animal that has to voluntarily turn on its consciousness. In Orient, you are thinking about your thinking. Okay? And no one else can do this for you. Only you as an individual can do it. And you may not be able to do it in this given circumstance, as well as another individual, but you cannot borrow another individual's Orient. It's all you, baby, because it's all your cultural traditions. It's your genetic heritage. It's new information and it's your previous exposure. And that's completely and utterly unique to you. Okay? When you're thinking about thinking and you're having metacognition, what you're doing there is you are narrowing your focus and you are formulating a plan slowly. But once you've oriented, once you've thought about your thinking, that automatically feeds forward into decision. Okay? And this, you don't have a choice about. Between here and here, you choose whether or not to turn on your brain or not and perform metacognition. A choice, actually, you have no choice about because like the band Rush says, if you choose not to decide, you still have made a choice. That's very true here. So you form a decision about what's going on around you. And in this decision, you're forming a hypothesis and you have to test that hypothesis with action. So that feed forwards again into an action which tests your hypothesis. But you need to do that quickly. And what I have found in emergency medicine is the greater your need to act decisively and rapidly, the greater will be your need to hesitate. Okay? So you have to do that quickly. Now, in this realm under Orient is a very big danger that we see all the time. And that danger is called normalcy bias. Okay? When things go bad, if you have an active shooter incident or your plane catches on fire, anything really bad starts to happen. The tsunami is coming. If a plane's been flown into your tower, there is a strong tendency on the part of your brain to shut down and try to pretend like everything's normal. It defends the normal. I see this all the time in the emergency room. Early on, I saw it myself. The 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, oh, 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 did he do that? Well, two and a half hours later after multiple testing in an angiogram of the gut, he was right. 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 normal C-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 with your khakis on and a nice pressed 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 normal C-bias and you have to protect against that. Okay. Now, as you feed forward and you go into decision and action, this is another real danger point right here is after you take your action, you're not done. Okay, what your action is is your contribution to the chaos. That's it. That's all you're doing. Just because you've taken an action and it seems to have worked, it's not like, hoo-hoo, celebration time. I see this every time I do a major resuscitation. The most stressful point in a major resuscitation typically is securing an airway in the patient, getting them intubated. And a huge amount of tension builds up to that point. And then all of a sudden the tube goes in and the oxygen level comes up and everyone breathes this collective sigh of relief. There's high-fives all around and then the patient crumps because they've been paralyzed, they've lost all their tone and they crash. The other thing is just don't celebrate. So let's move forward. And before you start this, the real key of an OODA loop, when you're competing with someone or the environment, is to turn it quickly. As soon as you've added to the chaos, then you observe again and you go through the loop. And if you can turn your loop faster than your opponent can, then you win. And this will demonstrate that and y'all will be familiar with this, I'm sure. Beware of normalcy bias. This is a beautiful explanation of it that I found on the internet, we'll just let it roll. Things have gone well up to now doesn't mean that it can't change all of a sudden on you, particularly when you're in an unstable environment. And lastly, don't celebrate, okay? Whether it's a football game, baseball game, you're in the ER or you've just gotten through a stressful situation, go. You don't wanna be that guy, okay? So now that we've talked about all this, what we gotta talk about is your internal state to be able to perform an OODA loop 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 gonna make you a good practitioner of the OODA loop. So you gotta check yourself before you wreck yourself because OODA loops 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 and 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's going from 90 to 120, your fine motor skills start to diminish. But your complex and gross motor skills are starting to ramp up some. But between 120 and 150, complex motor skills start to break down. You gotta 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. Has anyone in the room here ever been scared enough where they actually pissed or crap 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 degradating 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 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, this is talk, T. That's self-talk, you talk yourself up. You gotta talk to yourself why you're doing this. You gotta think about your thinking. So you gotta say, you can do this. You gotta consciously enact metacognition and 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 gonna 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. C, 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 thoracotomy and all the steps of it like you saw at the beginning with a C-booth at UCLA. I picture performing a cryophyrotomy which is getting into the windpipe 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 in to work every time I go so that when the hammer drops, I don't hesitate because hesitation kills in those situations. You gotta act fast. Focus, focus is a key word that you're gonna 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 gotta 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 practice enough 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. It's very important in a stressful situation. You wanna be open and expansive. You don't wanna be curled up and taking up less space. You don't wanna 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 noticed amongst my colleagues. Hi, hope you're enjoying the video so far. My name is Anthony Johnson. I'm the founder of the 21 Convention and CEO of 21 Studios. If you're tired of watching a ton of ads on our videos on YouTube and you wanna be part of a great community of men, click the box right here to start your free month at 21 University, the video streaming service for men. Thanks, enjoy the rest of the video. 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. And then finally, we wanna 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 conditioned red, instead of going into conditioned black, you just extend conditioned red out further, okay? And the way to do this is what Lieutenant Colonel Dave Grossman says, you don't ever, in a stressful situation, you don't rise to the occasion, you fall to the level of your training. So in circumstances where you think you're likely to encounter extreme stress, you need to train. And you need to train until you cannot get it wrong. Under extreme stress, no matter what, your performance is gonna drop by 30%. So people that really need to do it, trauma resuscitationists, special forces, people, SWAT teams, whatever it is, they train to 130%. So when that 30% degradation happens, they are operating at a high level. And then they also incorporate limbic learning. You really gotta do it under real duress because the emotion burns in the memory of how to perform. And then you have to have cognitive unloading, okay? And what that means is there has to be a lot of stuff that's on autopilot. So you standardize, standardize, standardize, okay? See a doctor wearing a doctor coat, if it's a good one, he knows where everything is in that thing. Reflex hammer here, stethoscope here, resuscitation cards here. Things that he needs are in a certain thing. A para jumper rescue specialist in the Air Force, a PJ, they have a triangle where they have tourniquet, airway, weapon. Everything is in a fixed location and they drill it over and over again. Prepare, prepare, prepare, have checklists and have predetermined decision points and triggers, okay? If someone is going to carjack you, you have to have thought of this ahead of time and say if someone puts a gun in my face, what am I gonna do? And I'm gonna allow myself to be carjacked and driven off somewhere, shot, tortured, dumped in the woods. Or am I gonna say, no, shoot me right here in the parking lot where all the cameras are. Or am I gonna grab for the gun? Have a pre-made decision point. For me, if I'm trying to get someone's airway, I'll try it one way, I'll try it a second way and then I'm cutting your neck. And I'm not gonna deliberate about it in the midst of a situation. I have made a predetermined decision point and that's important to have. So whatever you would make habitual, practice it and if you would not make a thing habitual, do not practice it but habituate yourself to something else. So if you have a bad habit, replace it and do it aggressively. And build your decision making power through simulation, through deliberate practice, meaning you're not just kinda chipping golf ball, you're actually using metacognition while you practice and you debrief with a teacher. And finally, my big thing, build physiologic headroom. The people that are in condition, that are optimally conditioned and know how to do hard things are the ones that can survive even when they're less well-prepared. So listen to all these lectures that you're gonna get from Bill de Simone, from Drew Bay about high intensity training and how to get yourself as physically optimized as you can. So in conclusion, to get to where you're able to do this, face your fears, imagine an alternative and get some skills. Remember the ootaloop and practice it. An easy way to practice an ootaloop is go out and throw a baseball with someone. And you throw the ball and you catch it and you throw the ball and catch it. All of a sudden start thinking about keeping my eye on the ball and actually think about the process. Think, am I looking where I want the ball to go? Think, am I watching the balls that comes all the way into my glove? And just experience the difference between simple cognition and metacognition and practice your ootaloops. And when you're doing your day to day work, think about it in those contexts and keeping the loop turning because you're contributing to the chaos and that's how you get control. And then beat the stress foolish Padawan. Remember box breathing. Remember self talk. Remember visualization. Remember your focus and having practice meditation beforehand in your posture. And then stress inoculate. Practice enough, have standardization so you have cognitive unloading. You don't have so much to decide all anew. Build your decision-making power and have physiologic headroom. You do those things, you'll be ready for truly stressful situations. With that, I'm ready to take any questions y'all might have. All right, who's got questions for Dr. Doug McGuff? Anybody written them down? We'll start here. Where does intuition or emotion come in with decision-making? Can we put that back to slide 12 that has the oodle-loop on it? That mostly is happening under orient. So intuition has a lot to do with your cultural tradition, your genetic heritage and previous experience. Intuition doesn't really just come out of nowhere. It's not inspiration. It's knowledge that you had on a conscious level in the past but you have filed away into memory. What happens under the stressful situation with intuition is you're taking a stored memory, whatever you can find that is at all applicable to the situation and it is pulling that file out of stored memory, bringing it over here and putting it in working memory. Working memory is ultra short-term memory where you're taking these files and applying them in real time and discarding them when they don't work and keeping them when they do. So it kind of resides under orient but it is not just inspiration. It's a product of your prior experience and just your general makeup in general. And then we have another question here. How does one manage or train existing trauma? Kim, would be a little more, give me some context. Something like anxiety, extreme anxiety, post-traumatic stress disorder, maybe how you, your process and train yourself to be prepared for the ER. I got it. So that kind of goes back to actually invoking the stress. And it seems counterintuitive but you have to put yourself in that stressful situation but only after before doing that that you've imagined an alternative or what your alternative response is gonna be. And this is kind of what people call fake it until you make it but it's really a little bit more about it than that. You got to think about what your current orientation or that problem is and the stress that it invokes and what your physiologic response is. You have to reimagine that as to what you would prefer your response to the stressor to be. And then practice that over and over and over in your brain and then go ahead and invoke that stress and try to enact that plan and do that over and over again. A lot of OCD loops are a loop that occurs between the prefrontal cortex and the limbic system and it just gets and you have the only way to treat OCD is to insert an alternative that breaks that loop. So you have to imagine this alternative and you have to in an over and over fashion whether through your imagination or repeated putting yourself in that situation insert the alternative response that you wanna have to break that loop. That makes sense. Thank you for the talk Dr. McGuff. I, you covered a lot of information some of which I've been exposed to and a lot of which I haven't. I actually have two questions for you. I think with most people stressors in their life are all around work. So it brings a lot of stress to people. And in that situation there are things that they can predict are gonna happen or things that they're stressed out about that happen regularly. And I was hoping you could just briefly go over how we could apply a couple things to help us in those work environments. Just practically more practical use of these types of visualization. Yep. Posturing and breathing, self-talk, that sort of stuff all makes sense to me. Is there something you could add that I could integrate into my daily life with work to be it less stressful? Yeah, I guess the first thing I would say is to actually do it, okay? I'm giving this in the context of, you're in an ER, you're in a battlefield, something's really going bad on an acute basis. But this applies on a more broad, less severe basis as well. So the first thing I'd say is to actually do it, okay? When you're at work, think in terms of ootaloops and think in terms of breathing, self-talk, actually do all those things, okay? But I think the biggest thing that I can give people about the stress as it relates to work is to go back to the Stoics approach, okay? You have to contextualize things to defuse the stress because particularly in modern Western society, 99.9% of our stress is completely an artificial construct. So you have to take the Stoics approach and say, okay, what's the worst possible thing that could happen here? And say, okay, if that happened, then what? So what? And then go from there. And if you realize that so much of these stressors and the things that you worry about are an artificial construct, then that defuses a lot of the stress in and of itself to the extent that you don't even have to worry about this other stuff so much. But doing both is very powerful. And that's how I'd suggest. If you have a specific circumstance about work, I'd be happy to discuss it with you, but. Time for one more question. Have you thought or have you used heart rate variability training in conjunction with box breathing to help modulate stress response? I haven't personally, but I'm not sure what slide it was, but it had the bell curve on it. I haven't personally, but there's a weird paradox here. There's research that shows that the people that have had stress inoculation that are able to go into condition gray, the peculiar thing about people with ice water blood that are able to operate at those higher levels are that their heart rate variability goes away. They have a metronomic heartbeat. And we don't really understand why, but your Navy SEALs, your special forces, people that work in critical care units, all those people that successfully manage this by stress inoculation and operating in condition gray, as opposed to trying to push themselves back this way on the curve with beat the stress foolish padawan, those people lose their heart rate variability. And we believe it's from chronic stress, okay? You also see that every once in a while, you drill sergeants will see this commonly, you bring a bunch of kids into Parris Island and they're just trying to stress you out and they scream and they dump all your stuff out and tell you, I mean, just create this horrible, artificially stressful environment to break you down. And every class, there's a handful of folks in the class, a handful of kids in the class that just cannot be stressed out. They just don't care. They just completely calm, nothing rattles in, nothing bothers them. And universally, these are kids that have come from very stressful home environments. They've had physical abuse, sexual abuse. They are chronically stress inoculated and that's not necessarily a good thing. So that's a double edged sword. I think the real key for someone like myself is to try to push this way on the curve. The early part of my career was focused on doing that. As I matured in my career, I'm focused more on doing this. Great stuff, Dr. McGuff. Let's give him a round of applause. Thank you guys. Hi there, I'm Anthony Johnson, founder of the 21 Convention and CEO of 20 Minutes Studios. And I wanted to say thanks for watching this full-length video. If you're not a subscriber yet and you never want to miss a video again, click the subscribe button right here or underneath the video. Thanks and I'll see you in the next video.