Podcast 132 – MoTR – Toughness Part I with Michael Lauria


Today, I interview Mike Lauria on the concepts of toughness and resilience.

The Rationale of Selection Courses/Indoc

80-90% Attrition for the PJs Indoc

One of the things that people, I think, find distasteful about selection programs in the civilian word is that it uncovers fundamental weaknesses and shortfalls.  This is no commentary on the intrinsic worth of the individual.  It doesn’t necessarily mean that they are smart or dumb.  But it is indicative of some inability or failure to meet a standard.  While it is hard for many civilians (and military members for that matter) to swallow, perhaps not everyone is cut out for a particular discipline.  Maybe we shouldn’t be forcing training, pushing people along, coddling individuals to maintain the outward appearance that a program is “successful” if an individual can’t make it through some sort of initial pipeline.  Perhaps a benefit of selection is making sure that the right people are there to begin with and the individuals that were simply not made for it are directed elsewhere.

I lost the source for the above quote, but I think it describes the process well. If anyone has it, please send me the attribution.

Builds an innate Espirit de Corps and a common thread of self and team-reliance

Residency as the Pipeline

Should we have culmination tests and exercises at the end of residency?

Stress Inoculation/Cognitive Tempering

Mike discusses four stages to do this right:

  1. Conceptualization-give a background of stress responses, why they happen, and what to expect.
  2. Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress. The latter is where we may be failing our learners
  3. Do a dry run to train in simulation without added stressors
  4. Run the same training with stress inoculation

How can we make #4 work in EM/CCM?

Sound, distractions, equipment failures, and deliberate poor communications

So what tools can we offer for #2?

Mike offers an acronym: Beat The Stress, Fool

  • B is for Breathe. Breathe tactically. See the On Combat Podcast for a description (and there is an app for that too: Tactical Breather App)
  • T is for Talk. Self Talk. Positive self-talk is used by athletes and any elite performance group.
  • S is for See. Visualization. Visualize yourself performing the task exactly how you want to see it done.
  • F is for Focus. A key word to activate the state you want. Mike has chosen “focus” as his word. We then had a brief discussion of the book, the Art of Learning by Josh Waitzkin. The author creates an entire relaxation and mindset ritual that eventually gets boiled down to a key word or short set of actions. You’ll be hearing more about this book on the podcast.

When Mike asked if I had anything to add to this excellent set of tools, I discussed this TED Video by Dr. Amy Cuddy:


So maybe…Beat the Stress, Foolish Padawan with a P for posture??

Too Much Macho Militarization?

Mike posted a Youtube Video Addressing this question

Cliff Reid’s Resus.me Post on Self-Defense

During the intro, I discussed the contentious self-defense post on resus.me


Some Anesthesia programs are already doing a modified interview process–thanks Lauren!


Here is the article: (non-tech-skills-interview-process)

Now on to the Podcast…


MotR – Mike Lauria on “Making the Call”

Mind of the Resuscitationist Wee

MikeLauriaMike Lauria is the @resuspadawan. You’ll be hearing a lot more about Mike when he comes on the show for an interview. For now, know that he was Air Force Pararescue, now a medic on the Dartmouth-Hitchcock Advanced Response Team (DART), and will be starting medical school in the Fall. He has a special interest in cognitive decision making under stress, aka the Mind of the Resuscitationist.

Recognition Primed Decision Making (RPD)

Sources of Power by Gary Klein


From 40-second Boyd. Read a summary on wikipedia


Cognitive Unloading

  • Standardization & Preparation
  • Checklists
  • Premade Decision Points and Triggers

Cognitive Rally Points (Stop Points)

  • Hard and Soft Rally Points
  • Take a Deep Breath

Build Decision Making Power

  • Deliberate Practice
  • Review Experiences
  • Timely Expert Feedback
  • Socratic Method-Suck it Up!
  • Simulation

Stress Inoculation

  • Cognitive Tempering
  • The Rule of 130%-do the basics better than anyone else
  • Limbic Learning-emotional reaction burns it in
  • Train until you can’t get it wrong
  • You fall to the level of your training

Stay Flexible

  • Cognitive Flexibility
  • Acknowledge BIases
  • Ask disconfirming questions

The Slides

Now on to the Lecture…


MOTR: Cliff Reid on When Should Stop Resuscitation


Cliff Reid gave this inspiring lecture at SMACCgold. He was tasked to talk on when we should stop a resuscitation, but instead he speaks about when we shouldn’t stop.

Mind of the Resuscitationist – Errors of Commission and Omission


I received an email from a friend and colleague on how to build mental toughness in our trainees. After hearing the case that spurred the question, I actually began to believe the problem is actually one of self-granted permission to act and the conflict between erros of commission and errors of omission.

Recommended Reading/Listening

Listen to the wee to understand what the frack I am talking about…


Podcast 118 – EMCrit Book Club – On Combat by Dave Grossman

Today I am joined by the master of all things Mind of the Resuscitationist, Cliff Reid of resus.me and the Rage Podcast. In the first ever EMCrit Book Club, we discuss a book I read years ago and recently reread:


On Combat by Dave Grossman has enormous relevance to resuscitationists. I feel the entire book is worth reading, but we zoned in on the really juicy bits.

Section I – Physiology of Combat

Chapter Two – Stress Responses to Combat

We briefly discuss bowel and bladder control as they relate to stress

Chapter Three – Sympathetic & Parasympathetic Responses

Parasympathetic backlash-a time of cognitive danger

“The moment of greatest vulnerability is the instant immediately after victory” –Napoleon

Adapt a 360 degree visual sweep for threats (keep looking at all of your patients vitals and remember to bag)

SWAT Team Acronym-L.A.C.E. liquids, ammunition, casualties, equipment; For us–check your team, immediate reset of resus bay, drink something, debrief

Burn off the adrenaline dump

Conflict with colleagues. Exercise, Punching Bags? If a horrible call is reported on the EMS phone, but never shows–run a sim to burn the epi.

Sleep Deprivation-Caffeine can be our friend, nicotine not so much. If you are too exhausted to perform, tell a colleague and take a nap.

Chapter Four – Colored Conditions

originally from Bruce Siddle, Sharpening the Warriors Edge

Heart rate and task performance: heart rates are a guide, getting there by exercise is not the same as by fear/stress, so HR is merely an associated marker
Yellow 90-120, Over 115 and fine motor skills performance degrades significantly
Red 120-150, a 145 HR seems to be the break-point for optimal performance of complex skills
Black >150 and badness ensues, (or >175 in the highly trained, they get a gray zone)

  • Fine motor skills-precision tasks
  • Gross Motor Skills-ape skills
  • Complex-a combination of maneuvers or use of multiple body parts

SWAT team breaking down door function in condition red (or gray), but they have trained until the necessary tasks that require fine motor have been practiced till automaticity

Unified Model of Stress and Performance

On Combat Unified Model

From Grossman On Combat

On Combat Heart Rate Diagram


We need to train how we fight
Stress Inoculation Training and (Academic Medicine 2009;84(10):S25)

We are currently wasting high fidelity simulation, it should purely be for stress training. Perhaps, we should create a hell week for our 2nd years.

Stay in yellow (alert, but with fine motor control) – yellow dot stickers to remind you

“I understand a fury in your words, but not the words” –Shakespeare from Othello

Tactical/combat breathing to stay in the color zone

Hicks’ Law – procedures should only be learned one way-preflush central lines, one way to RSI.

Section 2 – Perceptual Distortions

Chapter 1 – Auditory exclusion and tunnel vision

tunnel vision – the toilet paper tube

Chapter 2 – Auto-pilot

What is drilled in during training comes out the other end in combat, no more no less

Chapter 3 – Grab Bag

Time perception is sent awry

This is why you must not squeeze a BVM when stressed.

Chapter 4 – Memory

Memories under Stress are Suspect

Self Debriefing is flawed, debrief with your team.

Section 3 – The Call to Combat

Chapter 2 – Training warriors

Need to train the puppy brain, because the doggy will be in control

Triune Model of the Brain

  • Forebrain-Human
  • Midbrain-Puppy
  • Hindbrain-Lizard

Cleanse denial: not if, only when. Do not train to “If I get into a CICO situation,” instead, “When I get into a CICO situation.”

“In combat you do not rise to the occasion, you sink to the level of your training.” –Grossman

Principles of Training

  1. Never Kill a Warrior in Training-this only trains them to die. Every engagement should end in the proper behavior
  2. Try to never send a loser off your training site
  3. Never talk trash about your students-Punish in private, Praise in public

This is a great chapter for folks running courses/simulations

Section 4 – The Price of Combat

Chapter 5 – Tactical Breathing

Autogenic / Tactical / Combat Breathing


  • Breath in through your nose filling up your belly for 4 seconds
  • Hold for 4 seconds
  • Exhale through your mouth for 4 seconds
  • Hold for 4 seconds
  • Repeat x 4

If you read the book and have thoughts, please leave them in the comments below

Now on to the Podcast…


Podcast 109 – Mind of the Resuscitationist from SMACC 2013


This lecture was from the final day of SMACC 2013. It was based on a case I saw at Janus General Hospital.

Blakemore Placement

In the lecture I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet.

Now on to the Podcast…


Podcast 108 – How to Be a Hero with Cliff Reid


This was my favorite lecture from SMACC 2013. If you are not moved and inspired then your heart is made of stone.

This is a Cliff Reid lecture; if you want more Cliff, see these incredible lectures and podcasts:

I’ll post my own final SMACC lecture in 1 week and then we are done with SMACC 2013.

Want the Slides and a Beautiful Blogpost on the Lecture?

Head on over to the post on the Resus.me Site

Need an Audio-Only Version?

Right-Click Here and Choose Save-as

Now on to the Vodcast…

Podcast 106 – Making Things Happen with Cliff Reid


Mind of the Resuscitationist

This was Cliff Reid’s opening lecture from SMACC 2013. Cliff Reid runs the amazing Resus.me site and any listener of EMCrit knows that I have an enduring (and purely platonic) love for Cliff and all of his teachings.This lecture was on Making Things Happen and it is my #2 favorite lecture from the conference. My number one favorite was also by Cliff, but you’ll have to wait a bit for that one.

Want More Reid?

Want the Slides?

Need an Audio-Only Version?

Right-Click Here and Choose Save-as

Now on to the Vodcast…

Podcast 99 – Combat Aviation Paradigms for Resuscitationists


Joe Novak, MD was an F-15 Combat Pilot and now is an Emergency Physician. In this fantastic lecture, he brings the concepts of Combat Aviation to the art of Resuscitation.

The Boldface

aka the no-shitters things that must be absolutely incorporated into your memory and available for immediate execution. You should not need to think about what to do in these situations.


Cognitive unloading and guarantee of the performance of critical actions. Use after addressing the boldface

Prioritization of Attention and Tasks

In combat aviation:

  1. Aviate
  2. Navigate
  3. Communicate

In EM & Critical Care:

  1. Resuscitate
  2. Differentiate
  3. Communicate

The Cross-Check

Keep coming back to the global patient picture before diving into any minutiae

Efficient and Unambiguous Communication

  • Directive
  • Descriptive
  • Informative



Planning: Mission, Defined Roles, and Set the tone


Learning happens in the debrief


Pre-Flight Read Files

Can’t fly until you have read and signed-off on any new procedures or techniques

Ultrasound Podcast Guys’ New IBook Kicks Ass!

Screen-0005 5-25-2013 5.36.41 PM

IBUS Volume 2 can be found here

Need an Audio-Only Option?

Right-Click Here and Choose Save-As

Now on to the Podcast…

Mind of the Resuscitationist – Chicken Bombs and Muppet Factors

Cliff Reid adds to the MotR lexicon with Chicken Bombs and Muppet Factors