Oh, stress
oh stress


A whole-body response to an external stimulus that involves activation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system. The goal is to:

  1. Enhance bodily performance (better cardiac output, increased minute ventilation, etc.)

  2. Mobilize resources to sustain this level of performance (glycogenolysis, lipolysis, etc.)

The problem

If the source of your stress is a bear - no - a HONEY BADGER, then this stress response is great. But more often than not, the problem is not a honey badger. It’s a crashing patient. Herein lies a problem. Excessive stress degrades performance.

Excessive stress degrades performance

This is described well by the Yerkes-Dodson Law:

The Yerkes-Dodson law essentially describes a bell-curve phenomenon of stress. Too little is bad, too much is also bad. But there is a happy medium where we have optimal arousal and optimal performance.


Whenever we encounter a clinical scenario, we engage in an appraisal process. We evaluate the demands of a situation and compare them with our skills. We appraise situations as challenges if we have the appropriate clinical acumen to handle the task at hand. However, if we feel uncomfortable or incapable of handling a given scenario, we interpret it as a threat, become stressed, and paradoxically experience degradation in our performance as a result.

Stress management, just in time

So how do we combat the effects of acute stress on performance? We need to take some advice from Mr. T, and BEAT THE STRESS FOOL. This technique was first described by Mike Lauria in the Annals of Emergency Medicine and on the Emcrit Podcast


Beat The Stress Fool

  • Breathe

    • Capitalizes on the only physiologic function that WE can take control of during the stress response.

    • Square breathing (In for 4s, hold for 4s, out for 4s, hold for 4s)

    • Refocuses our thoughts on grounding ourselves prior to performing a task.

  • Talk

    • Most of the talk we experience in a treat appraisal is negative.

    • Reframe your thoughts and engage in positive self-talk.

    • I CAN do this, 'I’ve trained for this. I’ll get this on the first try.

  • See

    • Mental rehearsal. Essentially run through the steps of a given process (i.e. central line, cricothyrotomy, complex resuscitation) in your mind prior to actually engaging in the task.

    • Useful both immediately before a stressful scenario (e.g. walking to the room of a crashing patient) AND way before an event occurs (e.g. during your commute).

  • Focus

    • Transition from stress preparation to performance.

    • This is your “GO” word.

    • Takes practice to really see benefit - give it a try!

Take a listen to the podcast to hear all of our thoughts, and check out these great resources to learn more:

  1. Beat the Stress Fool with Mike Lauria

  2. Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress

  3. Not stressed enough? via HBR

  4. Fake it until you become it - TED talk by Amy Cuddy