Oh, Stress: How Acute Stress Affects Performance & How to Beat It
Experiencing stress during a code or crashing patient? That fight-or-flight rush may sharpen your performance—or derail it. In this episode of Pulmcast, we delve into the biology of stress, explore the Yerkes-Dodson bell curve, and introduce the BTSF (“Beat The Stress Fool”) technique to help clinicians stay sharp under pressure.
The Physiology of Stress: HPA Axis & Sympathetic Activation
When facing an external threat—real or perceived—your body initiates a stress response. This activates the HPA axis and ramps up sympathetic tone, increasing cardiac output and ventilation, while mobilizing energy stores. The goal is to:
Enhance bodily performance (better cardiac output, increased minute ventilation, etc.)
Mobilize resources to sustain this level of performance (glycogenolysis, lipolysis, etc.)
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.
The Yerkes-Dodson Law: Finding the Sweet Spot
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.
Appraisal: When Stress Helps vs. Hinders
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.
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
BTSF: Beat The Stress Fool—Breathe, Talk, See, Focus
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!
BTSF isn’t just for individuals—it elevates team performance under pressure. Stress awareness, shared language (“GO” cues), and preparatory rehearsal can help ICU teams stay coordinated and effective.
Take a listen to the podcast to hear all of our thoughts, and check out these great resources to learn more:
Attributions
"Belfast”, “Spring Solstice”, “Fluorescence”, and “Evenhanded” by Podington Bear is licensed under CC BY-NC 3.0 / Songs have been cropped in length from original form
“Heartbeat thumping.wav” by Doctor_Jekyll is licensed under CC BY 3.0 / Song was not edited or cropped in any form
“woman crying in deep grief” by tweedledee3 is licensed under CC BY 3.0 / Song was not edited or cropped in any form
“front door open.wav” by THE_bizniss is licensed under CC BY 3.0 / Song was not edited or cropped in any form
“Announcement-05.wav” by gollamar is licensed under CC BY 3.0 / Song was not edited or cropped in any form
ICU sounds, and nurses speaking by the pulmcast team
