STAT Leadership: Critical Incident Leadership S2e1

STAT Leadership is a fast-paced, no-nonsense podcast where three emergency physicians—shaped by years in EMS, military operations, rescue work, and disaster response—break leadership down to its essential, actionable core. Across the first ten episodes, they tackle the fundamentals: what leadership is, how it’s developed, and why character, communication, and self-awareness matter more than titles. Through stories drawn from high-stakes medicine, combat deployments, tough calls in the field, and the leaders who shaped them—real and fictional—they explore authenticity, followership, influence, networking, resilience, and the fine line between leading and managing. They don’t shy away from hard truths: leadership is earned, rarely comfortable, and always rooted in trust, consistency, and humility. Whether discussing how to mentor the next generation, handle transitions in command, or keep your head straight under pressure, STAT Leadership delivers grounded, practical insight from people who have led when the stakes were life and death.

The hosts launch season two of the Stat Leadership Podcast, aiming for advanced leadership concepts, guest leaders, and practical operational tips, while inviting listener feedback. JR recounts a traumatic cardiac arrest from a motorcycle crash in which he initiated a time-critical procedure briefly achieving return of pulse but ultimately losing the patient to non-survivable injuries; he reflects on how preparation, mental “if-then” triggers, equipment readiness, and practice matter more than the act of cutting, and on delegating room leadership while performing a procedure. The group discusses professionalism as unseen preparation, performance critique via video review and hot washes, managing fear, and JR’s post-event inability to focus and need for “me days,” counseling/EMDR, and healthy recentering techniques like box breathing and 4-7-8 breathing, plus cautions about chasing dopamine highs. They close with book mentions including Fight Club, Wisdom of the Bullfrog, First Blood, Range, and Less Than 1%

00:00 Season Two Cold Open
00:29 What To Expect This Season
02:32 JR Trauma Case Setup
03:03 Clamshell Thoracotomy Explained
05:17 Decision Making Under Pressure
07:50 Teamwork And Leading The Room
09:36 After Action Review And Recovery
10:52 Bravery And Emotional State
12:14 Triggers PACE And Practice
14:49 Fallout Scrutiny And Professionalism
19:51 Command Decisions And Preparation
23:20 Breathing Visualization Focus Cues
24:14 Crossing The Rubicon Moment
27:24 Invisible Discipline And Stoicism
28:57 Breathing Controls Stress
30:17 Box Breathing Breakdown
31:55 Using 478 for Sleep
32:44 Tools Beyond Breathing
33:51 JR Recovery Playbook
35:38 When Cases Haunt You
36:44 Hot Wash and Video Review
38:03 Reengage After Failure
42:31 Dopamine and Risk Cycles
44:53 Book Picks and Wrap Up

Top Gun Maverick  https://www.imdb.com/title/tt1745960/?ref_=ext_shr_lnk
Mike Lauria on the PJ Medcast  https://podcasts.apple.com/us/podcast/conquering-high-pressure-situations-mike-lauria-on/id1335582586?i=1000635788149
Batman Begins  https://www.imdb.com/title/tt0372784/?ref_=ext_shr_lnk
Fight Club by Chuck Palahniuk https://a.co/d/0dj3fgIC
Wisdom of the Bullfrog by Adm William McRaven  https://a.co/d/046gD2wp
McRaven’s graduation speech:  Make your bed.  https://www.youtube.com/watch?v=pxBQLFLei70
First Blood by David Morrell  https://a.co/d/0dj3fgIC
Less than 1% by Imamu Tomlinson https://a.co/d/0ftahpnr

Transcript

SPEAKER_02 0:00

When the couple comes in, leadership is everything.

SPEAKER_00 0:02

We analyze the data in real time, making the tough decisions under pressure. Welcome to Stat Leadership. Hello, Leader's Code Podcast listeners. Welcome to, I guess we would call this season two of our podcast Leaders Code. I'm Phil Moy from St. Louis.

SPEAKER_03 0:19

You know we're not Leader's Code, right? Leader's Stat Leadership.

SPEAKER_01 0:24

Sorry, man. Armst does it over again.

SPEAKER_03 0:27

No, keep it. Whatever. Redo.

SPEAKER_00 0:30

Redo. Do you want to bring us in, JR?

SPEAKER_03 0:35

Go ahead, bring us in. Hey, welcome everybody. It's the Stat Leadership Podcast. We're into season two now. Hopefully, by this point, you've gotten hooked on the previous 10 episodes that we released. So we're going to start releasing these on a more regular basis, on a probably monthly basis or so. But now that we got you hooked, we're going to keep uh feeding you. And yeah, so we got some good stuff in mind for this year. We're going to be obviously talking about some more advanced leadership concepts and also bringing some guests in, some leaders that we've learned from and been mentored by. And I think that we're going to have a whole potpourri of stuff. So whatever leadership position you're in, whether you are the CEO, the top dog, the chief medical officer, the department director, or you are earlier in your career and you're looking to move up that ladder, or you're a line leader that has a few folks that they're responsible for. We hope that something is going to speak to you from each of these episodes that we're going to be recording here. Understand that this is really informal. We don't have a script. We sometimes have an idea of what we want to talk about. And I I don't know if that's necessarily the case for today's episode, but I you may pull a little bit of something that speaks to you and helps you in your journey as a leader.

unknown 1:56

Yeah.

SPEAKER_00 1:57

No, I'm kidding. Thank you very much. Done.

SPEAKER_02 2:02

So we hope we also want to invite you to give us your insights or inputs. Engage with us either in the comment section or through messaging if you have topics in mind. If you have questions or follow-ups, I know I've gotten some outreach regarding a conversation we had last season about running meetings. So we do have some stuff this year where we're going to talk about operational kind of tips and tricks, things that leaders need to know to be effective and also to look effective to try and facilitate the process of leadership too. So definitely keep those coming.

SPEAKER_00 2:39

Yeah, yeah. And it's we've been chet JR and I have all been busy post-NAMSP with our lives. And I know JR has been texting us with the interesting case he just had where he is now the god of his emergency department from a rising god. But it had to do with leadership, I assume.

SPEAKER_03 2:58

Somewhat, yeah. Famous, no, infamous, notorious, maybe.

SPEAKER_00 3:02

That's uh maybe the trauma surgeons are possibly a little irked by you. I don't know.

SPEAKER_03 3:07

I don't I didn't seem mad. I didn't seem angry. What happened? Yeah, I had a I had a case where it was a traumatic cardiac arrest, a very unfortunate motorcycle accident. I got was very badly injured, and while en route to the emergency department, which was a short transport, he went into cardiac arrest. And in a traumatic cardiac arrest, most traumatic arrests are not survivable. They're injuries that uh you cannot be fixed no matter what kind of medical care you've got. But there is a fairly aggressive procedure that you can perform to address the potentially reversible causes. It's a bit of a Hail Mary. The survival rate is extremely low, but it's called a thoracotomy, and specifically in this case, a clamshell thoracotomy, which uh entails opening the chest and getting the heart uh out of the pericardium to repair any wounds in there, stopping bleeding inside of the chest, clamping the aorta to divert blood flow from the lower part of the body to keep it up here for the heart and for the brain, which are the most blood flow and oxygen-sensitive tissues in the body, and then and do internal cardiac compressions. Take the heart and squeeze it between your hands and try to get blood moving. So the patient showed up with very little warning to us. Now, usually when this procedure is performed in a trauma center, you have trauma surgeons that are there that are typically the ones that are initiating it or doing it. Sometimes it has to be initiated by an emergency physician. Our trauma service is outstanding. They're super responsive, they're great at what they do. And uh this guy, though, he showed up like in a rest within a couple minutes of our notification. And seeing that if you don't initiate this procedure within five minutes of the loss of pulses, then it is a futile procedure. This was that one case where maybe we can fix it. So I went ahead and uh initiated the procedure, cut across his chest and then opened his rib cage with a pair of trauma shears and uh exposed the exposed the heart and the lungs. And by this point, the trauma resident was there with me, and she was in there, hands in the chest, doing internal CPR as I'm clamping the aorta. And it was it was a fairly again, Hail Mary kind of heroic attempt at saving the guy's life. We did get a pulse back on him and did make it to the operating room, but unfortunately died of what we determined to be not survivable injuries. And yeah, afterwards, it's funny you do something like that, and I up until that moment, I thought, yeah, the hardest part of the doing the procedure is picking up the scalpel. It's not a technically difficult procedure, it's one that I've practiced many times, it's one that I've done both in the field and in the hospital several times, and it's big medicine, the though, to do it. And in thinking the hardest part is picking up the scalpel, and uh then I reviewed Dr. John Hines, his lecture, Crack the Chest, get crucified. And he says, if you think that's the hard part, then you're not you don't know the procedure well enough. And I thought to myself that, yeah, you know that that's right. I've made a deliberate study of this and other really important procedures. Certainly, they're procedures that will that will draw scrutiny once they're performed, whether that's a surgical airway or a resuscitative hysterotomy or amputation. So I've studied these things, practiced them, and run mental models of when I would do them, when would be the right circumstance, but to make sure that I'm doing it at the right time, that my intentions are honorable with it. And so that's what I realize is the hardest part. It's not picking up a scalpel to make the decision, it's the preparation, it's the maintaining the mindset to do something like that. It's the practice and banishing fear through the practice of the procedure so that the procedure itself is not scary. And that's the hard part. And so I was I was I had conflicting feelings when the uh trauma director reached out to me and said, Hey, I want to sit down and talk about this case with you. And it wasn't in any sort of confrontational way, uh it was just obviously this is a rare thing, and we want to look at it and see what we can do better. And and here's the video, because all of our resuscitations are recorded. And so it took me a couple days before I was able to watch the video. I was really worried, like, man, how did I perform? And would did I was I spinning my wheels? Was I being a good leader? Was I being a good example to the others that were in the trauma bay? And because I wasn't the only physician there. When I was in there, this was, of course, night before uh conference, and so there were no ER residents in there. The one of the other attendings, Allison Smith, she got the airway, which was a a feat on the in and of itself. Eye gel's in place, and there's a lot of vomit in the airway, so she effectively did a blind video intubation into a pool of vomit and nailed it on the first shot. Absolute hero stuff was awesome. And Chris Reba was kind of running the resuscitation pieces of that as well. So it was a really terrific team. And I had my own perspectives, but I was very head down in the procedure, so I'm not like really watching the whole room as as I'm doing it and I'm not having situational awareness of everything else, which is another point of when leading, you can do the procedure or you can run the room, but you can't do both. And handing off the stick to somebody else before running it, which worked really well here. Um when I finally got around to watching the video, I was happy with what I saw. That's not to say I liked everything that I did, like everything that happened in there, but overall, I'm like, I remained calm, quiet, very goal-directed, and communicated really clearly. So in that, I'm looking holistically at the room, but I'm really trying to appraise and assess my own performance in that. And just like an athlete, you go to the tape and watch what you did and see, or what can I do differently. Sometimes I go to the tape by watching other people in these situations. So by precepting residents and medics in actual calls or in simulations and providing some feedback to them. That is also the practice, that's deliberate practice on my part as well for how to act in those situations. At the end of the day, it was, of course, a tragic and very unfortunate case, but I was happy how the team performed. I was happy about my role in it and what I did. But it the other piece of this was that I hadn't really expected was that I the rest of the shift, I could not get organized. I was like walking around the emergency department, like going here, oh, I need to do this, oh, I need to do that. I couldn't focus. And that was even worse the next day. And I was at home and I had a couple things to do at home. I didn't have to go to work, but I could not focus. I was pacing between the bedroom, the bathroom, and the kitchen and getting my coffee and doing this, and I was just wired, having not had a whole lot of sleep, too. But I like, am I, okay, this is gonna be a down day, this is gonna be a me day. And I hadn't really recognized that before uh when I've been involved in these kinds of cases, because I've had several cases like this. I was like, oh, okay, and now I need to develop some sort of skill that uh involves how do I recenter uh uh after that? How do I pick up the pieces after that? Whether it's whether it's a success or failure or anything, just a fairly intense experience. Yeah, I have to develop some sort of way to unwind.

SPEAKER_00 10:53

Yeah, thanks for sharing that, JR. I think that's such a valuable kind of, if I were to put in quotations, case study of leadership. But I think it gives a lot of good insight into the pressures of, I would say, leadership or just being in that situation. And I'm gonna pull a thread a little bit in the in the very beginning here because I think it's important and I think it's something that's important because I have very young kids, a six-year-old and a four going on five-year-old. And it really does put a lot of things in perspective. And I have my kids come up to me and they're like, oh yeah, I was really scared to do this. And we always my what my wife and I do is yeah, it's okay to be scared, but that's okay because you still did it, and that's called being brave. And no one talks about how you feel when you're brave, is you feel scared, shitless. And that's like the epitome of braids. So I guess the question I would have for you, JR, is in that moment when you picked up the scalpel or had to make that decision, how did you feel? What was the emotional gestalt of going through your head or your I know as an as we're all emergency physicians here, we're all getting to that mode, but at the same time, to make that decision to we're gonna do this, yeah. How did you feel?

SPEAKER_03 12:14

This I fortunately I'd had a minute to before arrival to think about, like the what ifs. And this is an exercise that I do a lot with myself. I do this with residents of what if. And so I had certain triggers in my mind of if this then that. And I think that developing those triggers is so important as a performer, but also as a leader, to have mental walkthroughs of if this happens, what then. And I talk about this with airway management, with the development of a pace plan, which is a primary alternate, contingency, emergency. So you have four layers deep of your airway plan and so primary video learning, just go alternate, direct laurendoscopy, contingency, eye gel, emergency, surgical airway. And having that in my mind, so then if if a initial airway attempt is not successful, then you can move to the next step in the plan without a whole lot of time to think about it because you've already made the decision. And I think having those, that pace plan in your mind, and not just in some sort of nebulous ethereal, I'll crack the chest or I'll do the surgical airway, but actually having the equipment at hand, knowing where it is, and having it ready so that you're not like looking through your bag or uh looking on the shelf for the kit, whatever that that is. And practice banishes fear. That's that's a big thing. If you practice it enough, then the technical performance is not as uh as frightening to you. And I felt I had practiced it enough to do to understand the procedure well enough to perform it. Now, I'm not a trauma surgeon, I cannot do what those people do. They're the of course they've got so much experience with that, and that's going to be expert performance. But can I do it well enough for the timing that to do the timing right here? If you wait for a lot of these things until you're absolutely sure that it needs to be done, then your opportunity to save their life has probably passed you by. And it's like the surgical airway. A lot of folks are they, oh no, you can't intubate, can't ventilate. And so they keep spinning their wheels to try to intubate, and then the patient codes. And it's like now, okay, now I can do the surgical airway, but man, like the the patient, we should have done this five minutes ago, and we may not have lost the patient at that point. So I think at the moment it was like, oh, I guess here we go, we're in it. But it was at that point just focused on the technical procedure itself because the decision was made. So I didn't have a lot of conflict in my mind. But I will say that the uh my previous experience with this procedure has been the as far as the fallout, the aftermath, has been mixed. And and I've had some very strongly negative post-procedure experiences where I did one on a on a stab uh stabbed patient that we were transporting the hospital. I initiated the thoracotomy in the field and did get a pulse back, did get ROSC, and ultimately he died. But I was invited to trauma conference and to talk about the case. But once once there, I realized they had no intention for me to talk about the case. They just wanted to rail at me and look cool in front of the in front of the surgeons and so forth. So it was like, okay, that was a very strongly negative experience, which is, I'm sure, what they intended for it to discourage me from considering that procedure. But I stand by it at the what I did at the time there. But like knowing that, oh man, this is gonna be a big deal. And I can only imagine a resident having to make that call, a surgery resident having to crack a chest without without the attending. And man, what if this goes wrong or if this is determined to be the wrong choice about how miserable their life would be after that? So that was in my mind at some point, this is gonna hurt later. That I felt that at the time, I felt that afterwards too, okay, here we go. And wake up in the morning and there's there's 50 text messages on my vote from people. And um I I was I was a little bit trepidatious about that, knowing that the I knew my intentions were honorable, I knew the procedure was indicated, I knew that I knew how to do it, and it was within my scope of practice. But the feeling of the fallout was something I was uh really not uh expecting to enjoy. A very professional way to put it.

SPEAKER_02 16:39

There's a lot to unpack in the story, but also in the surrounding issues, JR. One of the biggest ones is that I think because of the easy access to video and web-based documentation and all, I think people don't realize that even just making that decision and then taking that action, this was not arbitrary. There was a career's worth of professional judgment, intense preparation, reflection, and effort that went into, not to mention the moral accountability and responsibility you feel to treat and care for suffering humanity, right? All of that led up to the decision. I think people don't realize that sometimes this was an intensely professional and a very intimate thing you did for a human being that was dying. It was a fellow human and you intervened in probably one of the most extreme ways, right? So I think sometimes the I don't know if we're desensitized as a culture just because of access to this sort of stuff or what it is, but there's a there's so much more inside that. And then even for our non-medical listeners, there are incredible leadership lessons in this story, I think. Just an example, for example, would be the fact that one of the things that marks this as intensely professional. And if you ask the average, say, sports fan, what's the difference between a pro and not, they'll say, Oh, they get paid for it. And I'm like, no, man, the salary is not the thing that determines professionalism. There's this whole self-regulation, setting a standard for ourselves, so many other things, right? So your preparation up to that point was, I think, a defining part of your professionalism. Everything you did, whether it was procedural knowledge, playing the what-if game, having the equipment ready. I think the big one of the biggest differences between professionals and novices is novices hope to get it right. Professionals prepare and train to the point where they cannot get it wrong, right? That doesn't mean mistakes don't happen, but there's a level of preparation there that I think often goes unnoticed. And I think the actual cut is probably the tip of the iceberg, really important tip of the iceberg. But I think the intense effort and commitment that you were showing before you even did the procedure is often lost because that's backstage and people don't see that.

SPEAKER_00 19:12

Yeah, and I'll piggyback on your metaphor, chat, that this is truly yeah, the tip of the iceberg. All your decades of emergency medicine experience training led up to that. And sure, we could you could I know as a fellow physician, you're picking apart every little second in your head, which is why you were so jazzed up, probably afterwards and days afterwards, and everything. And you made it look easy, and I that's it's not lucky, it's based on all your training. And I would say that reminds me of the story I just read, and you guys are military, so you're like, oh, you guys didn't know about this. But it had to do with the Admiral Nimitz. He was the Navy Admiral in charge of the whole Midway assault, one of the most pivotal naval battles in World War II. And Japan was there, and they had cracked the Japanese code, but still there were a lot of variables that led him to have a lot of self-doubt and said, Are we gonna do this or are we not gonna do this? And it reminded me of when he talked to his mentor and his mentors, Admiral Nimitz, when you're in command, command. And that's basically it, right? We can pick apart an album. Oh, I felt a little hesitant. I had this previous experience where I had a negative, I was the whipping boy for all the trauma surgeons in the trauma team, and I still stand by my experience, and that still that experience reinforced your experience here. And I think you did the phenomenal thing of sure, you could have had the self-doubt where you talked about airway people hesitating to do the crike when they should have just jumped and done the crike. You had done all that training, all that mental exercising, and then you said when it came time to command, you commanded. And I think that in itself is a flag in awesome leadership there.

SPEAKER_02 20:58

There's also a contemporary kind of movie scene that plays over and over again. If you've seen Top Gun Maverick, yeah. We repeatedly hear them say, Don't think, just do. And my biggest concern watching that was we're gonna have a bunch of novices, you know, not necessarily imbeciles, but people who have never put the time in to actually ever think, that are just gonna walk around going, don't think, just do. So in JR's case, he could just do because he'd spent decades thinking about this and preparing for it. So that ability to just do comes from a ton of backstage preparation and leaving nothing to chance. The pace plan is so brilliant. The primary alternate contingency emergency. And yet it's also very foundational. My military medics had pace plans. Now, it just so happened that was part of our training for them. We expected them to have that. We asked them to tell us about. It before it happened, and then we do this with our residents. But JR, other parts of this and Phil, that Nimitz story is so perfect for this because an accountable person is going to feel nervous, even if they are fully prepared, right? So at some point we just have to execute and just go ahead and initiate the action that we know is right. But JR, the other thing was the after procedure kind of experience that you had, the the professional reflection, which is in special operations, we often call it performance critique, where we go back deliberately and walk through it like every minute of an operation and go, what happened? You did this, I did that, you did that, why? How did it work? What could have been better? Blah, blah, blah. And then we dissect it all the way down to the outcome. And it's not finger pointing, it's really an unemotional and deliberate way of looking at what could have been done better and what was done well. So we'll repeat that. And then there's the other part, right? It's not nearly so unemotional or scientific. You felt it at a kind of physiological level. You had done something extreme. It was done professionally, but man, the body still makes you live with that for a while. And I think there are some things we can talk about, about I guess behaviors or activities we can do not to avoid that after effect, but to get it back under control. And Phil knows one of these. It's box breathing or 478 breathing. These are highly effective and proven techniques we can use even in the moment.

SPEAKER_03 23:32

I think for me, the next day when I had been, I think I slept for three hours and then woke up. And that's still I and I was as I realized I was spinning my wheels for the first couple of hours of the day, I recognized, okay, this is just gonna be a me day. And that I am not gonna expect anything of myself, I'm not gonna expect to get anything done. And I'm and then I'm also thinking, hey, okay, what about my next shift, the next time I go into work? And which I did the following day, and it was fine. I could back to go back to normal and and that's it. But using the movie reference that you just quoted there, Chad, with Top Gun Maverick, to me, the pivotal moment for this procedure was was similar to in that scene that you're talking about when they're flying in, they're getting ready to make the run, and the the admiral puts it on Maverick to say, All right, it's your call, and you do it. And he goes, Dagger attack. So at that point, that moment, that was the we're doing this, and we are fully committed to doing it now. And Mike Loria talks about this with some of his stuff that he's written and broadcast on mindset for these kinds of situations. And the Steve Rush, the beat the stress fool. Breathe, talk, see, and focus. Breathing like the box breathing or aervedic breathing, whatever the that technique is, getting control of that breath, doing positive self-talk, things like you can do this, and seeing it, visualizing the procedure. When you talk about Michael Phelps, who's one of the most decorated Olympic swimmers in history and phenomenal athlete, would visualize the entire race from being on the platform to entering the water, each stroke, the turnaround, visualize, mentally walk through the entire race. So visualizing that. And then the last thing being focus word, some kind of verbal cue to yourself that says, all right, it's go time. And when uh when I'm doing a uh an intubation, a rapid sequence intubation, for me, that focus phrase or word is push the drugs. And we've prepped it, we've done the timeout, we've uh everybody's got their roles understood. Uh, and then okay, now we are committed to it at this point. At that, even splashing, in if you've ever been in a thoracotomy, like in a military setting, in a combat surgery setting, it's when you hear the doc say splash, then you uh to throw the iodine over the chest and get out of the way. And so, like for me, I grabbed the iodine and what how long has he been in arrest? And they're like, just a couple minutes, he arrested. Okay, just turned and splashed. And like, all right, now at that point, that was the decision point. That like, all right, I am committed to this and I'm committed to see this procedure through. And I think recognition of that crossing the Rubicon moment that I think is helpful in any leadership position. The metaphor of crossing the Rubicon in the Roman army, once they crossed that Rubicon River, then that meant that they were that was that point of no return. We're leaving Rome, we're going to wherever this is, and we're gonna see this through. And so recognizing that moment and then committing yourself to it and and your team to it, and going from there. It's not to say you can't adjust fire, you you absolutely have to be somewhat flexible in that and be willing to do that. But at the same time, like doing each step after that point in half measures is probably not gonna do you or the people you are serving any good.

SPEAKER_02 27:19

And I think the run-up to all of that is is as important, or maybe even more important, right? If your equipment had not been ready, then it didn't matter when you crossed the Rubicon, you would have been unprepared, right? So not only was the commitment, the ability to decide to stay committed to it, those were huge, but the quiet discipline, the preparation, the ensuring ahead of time that all the pieces that you needed were in play, those are the invisible parts that I think novice leaders sometimes miss, or that people who are still either learning how to lead or maybe don't know how to lead sometimes miss. Because what they see is you standing there with the flag waving after restoring vital signs. But what they don't see is the boring, unsexy ensuring that the trauma kit was ready, right?

unknown 28:10

Yeah.

SPEAKER_02 28:10

One of my things that I'll teach sometimes, there's three things I always say, and one of them is control what you can, but accept everything, right? So you have to accept the nature of the circumstances, whether you love them or not. And then you do have to take control of the parts of it that are under your control, which also means the time leading up to it.

SPEAKER_00 28:29

Marcus Aurelius, some more Fati. Love your fate, control what you can and just love the fire that you're in. I'd like to pull the string on kind of the after fact because I think that's a fascinating part about your story, JR, about how you said you couldn't focus after that patient, but then also a couple days. And if you're willing to share a little more detail, that'd be great. But first, I guess for our audience here, Chet, could you explain or define box breathing or 357 kind of breathing kind of thing you were talking about?

SPEAKER_02 28:58

Yeah, it's very interesting that many of us may believe that our physiologic response, our rapid heart rate, our sense of anxiety or feeling amped up, many of us feel that those are out of our control and there's nothing we can do about that. And in a way, that's true. We're all human and we are going to have a human response. On the other hand, surprisingly, there are things we can do. Nobody's gonna be able to sit down and say to their heart, slow down and make it slow down. But there's great science demonstrating that if you can control and regulate your breathing in a systematic way, that you can measurably and reproducibly bring down your heart rate. And in the studies that have done this, that people actually are able to bring down their blood pressure and get everything under control, and it even affects neurotransmitter levels. So it's not a do it for the first time in crisis kind of skill. It's actually a practiced skill. What I will do is do one or more of these breathing techniques at least once a day. And that way, if I need it in the moment, I can do it. So let's talk about the breathing technique. So breathing the box is something that martial artists use, snipers use, a variety of people who work in high-intensity professions that require a steady mind and a steady hand have experience with this. And the box is simply a mental construct. So you inhale for four seconds, then you hold your breath for four seconds, then you exhale for four seconds, and then you hold that empty breath for four seconds. So if you do one of these cycles, it's good. If you do four or five or six of these cycles, there's an immediate and measurable reduction in heart rate, decrease in blood pressure, a sense of control. Like any physical skill, it requires practice. So the very first time we do it might be like the first time we ever tried to walk. We're probably not going to do it, might be like the first time we tried to ride a bike, wasn't very coordinated, didn't get very far. But with sustained attention to it, we can learn. And then the other is like a 378 or a 478 breathing. And that's really just inhale, hold, exhale that many seconds. And the key is to practice this. And it's it goes back to the JR thing. Or you've done it too, Phil. You're a triathlete. Nobody does more preparation before the day, right? The race is one during your training breaks, it's not necessarily one on the day of the race. And this is the same. We just got to put in a little bit of time, make the investment, and then later reap the reward.

SPEAKER_00 31:47

Yeah, an audience. We this just happened at NAMSP. Chet introduced me to the 478 because I I saw him the second day of NASP, and I was like, man, I'm exhausted. I had just bad sleep. My mind was racing. Because when you're at NMSP, there's a lot going on, and you have a lot of things that are tasks that it's on your task list kind of thing. I was like, Chet, man, I'm tired today. Worn down. He's because I couldn't sleep. And Chet gave me this advice about the 478 breathing at night when he when he has difficulty sleeping. So I do that now when I get my bouts of insomnia when I'm just like wide awake at like two in the morning, I'm like, oh, get to sleep, Phil, get to sleep. That doesn't help out when you talk yourself and try to force yourself to sleep. But I thought that was an invaluable tool to practice and to use when you're getting amped up like that. That's thank you for that.

SPEAKER_02 32:36

Yeah, and I'm so glad that worked. And I'll tell you, I think a lot of times we're gonna feel what we feel, and there's no sense in denying it. In fact, the sooner we accept I'm feeling this, the better off we are. What we don't have to do is stay immersed in it or be a victim of it, right? We can accept the condition for what it is, and then we do have tools. Sometimes the tools are breathing skills, sometimes it's some sort of activity or meditation we can do. Sometimes it's speaking with a peer or colleague or a professional. If you have an experience and then it's intrusive and you really can't get by it, ultimately we may need to sit down with somebody and have a conversation with a professional counselor or something like that. And these are all tools in our toolkit. So everything we have from kind of personal level intervention and reset activity all the way up to professional counseling might might be useful. And honestly, all of those are fair game and are in play to keep ourselves intact to come back and lead another day, right?

SPEAKER_00 33:43

Yeah, yeah. And I think back to JR's story, what I love that you did, JR, was you had the insight and you explicitly said to yourself, okay, this is gonna be a me day. You knew that you just weren't in it. So uh if you're willing to share with us, and feel free to say, no, I don't want to. How do you this is a recurrent thing, especially in our profession of emergency medicine, right? And well, this is gonna happen again. When you recognize this, what do you do personally to get through that kind of area where you're unfocused, you're just either energized or just not quite yourself after a scenario like that?

SPEAKER_03 34:23

For me, lowering my expectations of myself and I don't mean I don't mean professionally, knowing I'm I've always got a list of things that I want that to do and stuff to do around the house and more projects I want to work on and that sort of thing. And recognizing like, hey, it's not gonna get done today, and and that's okay. And I can just take some time, go to the gym, take a walk, and just just relax and and put my feet up. And uh my wife is so good about encouraging me to do that. She's just why don't you just relax today? And uh she's really good at validating that. And it's okay, and I know it's a me day, not a me year. It doesn't mean I'm a lazy piece of shit, right? Um I'm just taking a day to recover and relax. And I've been in a lot of high stress situations, I've been in mass casualties, I've been in active shooters. I've it I so a lot of these feelings that that happen are not unfamiliar to me. And and looking back on on a lot of these high consequence events, the ones that you feel went, they fade pretty quickly from memory. You remember them, but you don't live in them. They don't visit you when you close your eyes. The ones that you don't feel went well, they keep coming back. And there was an incident I was involved with in 2009 that still keeps coming back. And it it uh you're trying to recognize, like and again, do doing the professional examination, the that dispassionate sort of hot wash with myself, I have re-examined that incident more times than I could possibly count and come to peace with here's what I could do better, this is what I wish I had done differently, this is where I think it I went well, and that but it it's still a hard time uh with it, so it still pops up. And so yeah, doing a little bit of uh seeking some professional help, and it's funny because I didn't seek professional help around that incident, and it's just years later, and as I'm talking to the therapist and doing the EMDR and that, and said and this came up, and so it's oh yeah, okay, that's still living with me. And I think there's a couple of things to banish some of those. One is it honestly being able to see the video of this was really helpful ultimately, even though I put it off for a couple of days, I'm like, man, I'm not sure I want to see it. And so I did, but I was able to objectively look at it through the lens of video and say, Yeah, okay. I didn't do as bad as I thought I'd and I can give myself a little bit of a little grace for this and pull some lessons learned from it. So that was helpful. Hot washing with the crew. So we do have a a habit in my emergency department that after a resuscitation that we get the all the staff together for a hot wash for a few minutes to after we've cleaned the room up and gotten everything back to normal, if you will, then we'll just all get together and hot wash that real quick in the trauma bay and talk it through. I found that was extremely helpful as well. Examining it is a big part of that, so I can then let it go. So I don't have to keep thinking of it through my mind and running it over and over because you're thinking of it through an emotional perspective, through an emotional lens of the time that you experienced it. And so you being able to do that with video and then really say step back from it and watch watch myself in that. So that that was helpful. The other getting back on the horse, getting back to work is really good. And I know other incidents that I don't feel did as well, getting back in and having the chance to prove myself again, having a chance to do another case, which is almost like a do-over, then that that helps. And I remember I saw Admiral McGraven give a talk and just a fascinating talk. And I asked him, Can you give me an example of a time that you failed? And because that obviously he's a very storied career and being an incredible leader. He gave us a very personal story of when he was relieved of command of a SEAL team. And and that going home, I mean, I'm not sure, I'm not sure this I'm cut out for this because it's a big deal. And the Navy, it's a big deal in special operations. And talking to his wife, and she said, You've never really backed away from anything, you've never given up on anything in your life. And he said, sure enough, things being what they are, that chance to prove yourself again comes along. And it wasn't very long before it came along, and he was able to get back on the horse, if you will, and prove to himself and others that he is a very capable leader.

SPEAKER_02 39:11

Key, that's one of those things in crisis. It's human nature to after the fact withdraw, but nobody ever talks about how long to stay withdrawn or you know how to get back on. And then sometimes there's a tendency, especially if you look at athletics, to say, forget about that putt, get back and make the next one, forget about that interception, forget about it. And you don't really want to forget about it, but what you do need to do is move past it, right? So you can't live in that moment over and over again. If you forget about it, you probably do it again, right? Now, the reality of it is if you live an active life, one of contributing and leading, for example, then you're gonna repeatedly have opportunities to either succeed or fail. Hopefully, you're not failing on the same thing over and over again, right? That's the fear everybody has. But the reality of it is we're not gonna get it right every time. The key is proper preparation, learning from not only our mistakes, because none of us is gonna live long enough to make every mistake and learn from it. The key is to be a student of life and learn from the leaders that have gone before you and everybody around you. And now you're elevating your game. And then having gone through this crisis type of experience, at some point we do have to re-engage, right? Get back in it and you and get a few more reps in there, restore our confidence. Oh, yeah, okay, I can do this. And the example I always use is we overthink these things sometimes. I think we should think it. But if every baby that was learning how to walk thought that it was a catastrophic failure to fall down the first time they fell, oh, I suck, I'm never gonna be able to do this. We'd all be crawling around. There'd be nobody walking in the world, right? Because we'd just give up as soon as it happened. But those little babies are teaching a very important lesson, which is get back up and get going. You got this, and you're gonna fall again, that's a reality, but you're also gonna get back up again. And it is harder than that, but I think that it's possible too. And I think JR, your mature approach to it. And did I just say JR and mature in the same sentence?

SPEAKER_01 41:28

Nobody believes you. We're putting that out, we're putting that out. This is where the internet comments start snapping up from all my friends to this. And I just lost all credibility. Dang it.

SPEAKER_02 41:39

But that approach is so key, right? You did the thing, you had done the preparation before the thing, you felt a very human response to it, and then you re-engaged. You're not Superman, but I think that is exactly what we are meant to do in leadership positions. And I think that's part of the magic of it is within reach for all of us, but we do have to get in there and do it.

SPEAKER_00 42:02

Batman begins, JR. Why do we fall, Bruce? So we can learn to pick ourselves up.

SPEAKER_03 42:08

Now I have to figure out the difference between getting back on the horse and trying to and dopamine stacking because that was my instincts and critical incidents. I've been involved before, like, all right, cool, let's go to an X1. All right, I'm gonna go home and then I'm gonna come back and we're gonna do this trauma call again. Chasing that as well. I think that's something to I think that's something to be cautious of. There's a guy who gave a really good talk at NTOA. I was a police officer that was stroke task force and who got very badly wounded, and he was talking about the decisions leading up to that, that incident, which he said was just a tactical error on his part. And why? Because he's going out, he's kicking doors and taking down bad guys and doing it again and again, and just kept chasing that experience. And so then it one time it bit him really badly. And so, like when you have that high and then that that low feels really low, and then you have another big high and another big low, and in between, and then you start trying to raise those lows. And this is why folks that tend to be in these roles that of emergency medicine and first responders, combat vets, and so forth. That's why you start engaging in risky behaviors like alcohol use, substance abuse, really a really risky sexual relationship, all these kinds of things. Start trying to boost that dopamine in those lows in between those highs there. And my highs are not as frequent as they make the rules, but I recognize it between between sort of sucks. Oh yeah, feel that, and it's all it's all chemicals, it's all brain chemicals and stuff that you're that you're dealing with. So recognize that too, that yeah, it's okay to feel weird the next day. Yeah.

SPEAKER_00 43:58

Great. Well, on that note, should we We take it to our next segment, or what do you guys want to do now? We're 50 minutes in. We don't want to make this too long. Although I'm sorry, JR. This probably was a little more personal than you were expecting. And I apologize. I didn't intend for this whole episode to go that way.

SPEAKER_03 44:19

It's not like Michael Clark Duncan and Arthur J.

SPEAKER_00 44:28

Fight Club right now. Well, really okay because I've actually I've seen the movie, I love the movie, but I'm like, I want to read the book and everything. The book is the movie is very faithful to the book, and it is very enlightening. And it's also uh it's still pertinent today with the the issues with masculinity and the bro culture and everything, but it has that subtle delve into why we're having these issues, especially in the masculine world today. So uh it's surprising how pertinent it is. But I would say the other book I'm reading right now is speaking of General McCraven, JR, is The Wisdom of the Bullfrog, a short book, but it's about leadership. And it's actually if you've gener for our audience members, General McCraven gave that wonderful UT Austin graduation speech about make your bed. That's probably the number one thing you should do every day is make your bed, right? And he just phrases things so well that it just clicks with me. So that's another book in the reading that I really like and enjoying right now.

SPEAKER_02 45:29

Well, that's very cool. And uh, by the way, not to be too picky, but Admiral McCraven, he'll probably uh come punch us in the arm if we call him general. But so that's okay. For civilians, they are all the same rank.

SPEAKER_03 45:44

That's not what he does.

SPEAKER_02 45:46

They're all called flag officers or general officers, so the Navy calls them admirals, the Marine Corps, Air Force, and Army all called them general. But I'll tell you, another book that had a movie based on it that has a very different outcome is First Blood. If you have not read that book, the movie First Blood always resonated with me. I'm a fan of the way Sylvester Stallone portrayed Rocky, the way he portrays John Rambo, at least in the first movie. I'm not a huge fan necessarily of uh what follows, but interestingly, since my my service in the Air Force ended, or honestly, after my everything was fine until like my third deployment, and then I started carrying some baggage with me. And it there's the very end scene of First Blood, if you haven't seen it, Rambo's holed up in in the sheriff station there or in the office. He's gone off the rails, the whole town is now the gas station's on fire, and the ammo shop and gun shop has been torched, and it's on fire, and ammo's cooking off everywhere. And Troutman comes in and goes, Look, man, it's over. All right, enough. And Rambo loses it, right? So what was interesting to me is first of all, the very end of the book is very different from the very end of the movie. So, spoiler alert in the book, Rambo is a complete lost cause, and it's not Kerbal Troutman, it's a captain, much lower in rank, more of a company level leader, and he shoots Rambo, and that's how the book ends. Rambo's dead because he's just too far gone and he's lost it.

SPEAKER_03 47:29

He's also murdered murdered some innocent people in war too. So not that. Absolutely.

SPEAKER_02 47:36

Yeah, he doesn't get executed, but he's still at war. He's treating this town like it's it's at war, and Troutman kills him. So when I read that, I was just crushed because I'd never read the book, but I'd seen the movie. I went back and looked through some veterans groups that were involved in the original screen screenplay creation, and Stallone wanted the movie ending that actually came out. The producers wanted the book ending. And they fought about it. They actually had to stop production for a while. And when they initially rolled it out, they actually played the book ending in some theaters and the the movie ending, the current movie ending in other theaters, and were there to observe audience reaction. And when they played the book ending, people had an a vocal and negative reaction, shouting at the screen, you don't just do that, it's not his fault, that kind of thing. And when they played the one Stallone was advocating for, there was a huge response, especially on behalf of the veterans. They're like, in four minutes, this quiet guy said all the stuff that's bothering us. He identified our issues. We don't belong anymore, we don't fit in. But anyway, as far as books go, now that I've spoiled the ending, do check out First Blood. It's interesting. I'm always interested in how what movies are based on. In terms of nonfiction books, I just picked up a book called Range, How Generalists Are Poised to Succeed in a World Full of Specialists. So stay tuned. I'll tell you more about that once I get into it.

SPEAKER_00 49:09

Great book. I love that book. And in regards to your first blood, it I remember watching it a kid. I was like, oh, what a cool movie, Stallone in the jungles of Seattle, Washington, killing people. That's awesome. But then when you watch it as an adult, you're like, holy shit, this is all about PTSD. I'm dealing with that. And I was like, Yeah, wow. And then I thought the acting, especially at the end with Stallone breaking down, I was like, this is a phenomenal movie. And I had no idea that other aspect that you talked about, Chad. So what a what an interesting story there.

SPEAKER_03 49:39

Some of the backstory that is not as clear in the movie is the character of the sheriff, who who and why he has such such contempt for John Rambo is that he himself was a Korean war vet. And there's that that feeling of being forgotten, and that like all the attentions on on Vietnam and everything there, and where too had served honorably and and was kind of left behind there. And I thought that was good. That did really put a different light on, oh, okay. Like I can see where there's some resentment coming back here. But I appreciate that they did the ending they did in the movie rather than the book, because I think there is such a bias toward veterans by a lot of folks who have not been in. And is yeah, everybody's yellow ribbons, yeah, thank you for your service, all that kind of stuff. But there's also a very, a, a very definite, like you you look at somebody who is a combat veteran, is like is this somebody who's like all traumatized and about to snap and do something terrible? And I think that in if they had done the movie the way that they did in the book, that's the image that would have been portrayed. And I think that would have reinforced some of those biases and prejudices that folks have towards us as vets, and I I would not have appreciated that at all. So I think what they did with the movie was it did treat a lot of these issues with nuance, and I enjoyed that. But when I read about Denehy's character, and he's feeling kind of left behind here and in with our recent conflicts here. I'm an Iraq veteran, and we've got Iraq, which came to an end, and then more or less for us, not for the Iraqis, unfortunately, but that that came to an end. But Afghanistan just went on and on, and that was there was so much focus on that. In fact, even my second tour in Iraq, I was feeling that because Iraq's kind of drawn down, it's not getting the attention, and there was that feeling of that, hey, we're still over here, man. We're still doing this thing. So I could feel a little bit of how of how Denehy's character felt in that moment.

SPEAKER_02 51:54

Yeah, it it just real quick, I felt that way in the spring of 03 before Iraq was kicking off because we were sitting out on the Pakistani border and we kept hearing news reports of everything's fine, we're gonna be able to do this in Iraq and maintain two theaters, and we're sitting there looking at each other, going, We're having a hard time getting resupplied. We cannot get the even medical equipment that we need. How is it that we think we are okay in both places when our boots on the ground experience is so different? So, anyway, the perspectives that and I'll I'll tell you the other thing just real quick. Sorry, JR, I know we were moving there, but I think if a good thing came out of that, I often say nothing good comes out of war. And then I add that unless it's medical innovation, right, that happens. We do get better at some of the trauma care. I I think the other thing is the depending on your perspective, a sense of compassion and attention to your fellow human being. Like I to this day, I can't stand watching somebody eat alone without company, because we would be sitting there at Thanksgiving or Christmas in a tent somewhere. You'd get all these American and coalition folks eating together, and one guy would be sitting alone at a table on Thanksgiving, and I'm like, what the heck? So we would go and sit there, and okay, if they want to sit by themselves, that's different. But nobody should really feel that isolated, and not only in a combat zone, but really back at home also, right? That that awareness of people, hopefully, those are the kind of things that we can harvest out of the negative experience of war. Anyway, I'm back. We can finish talking about the whatever book you're reading, JR.

SPEAKER_03 53:36

Let's let's have it. So, right now I'm reading a book called Less Than One Percent. And I think actually one of you may have recommended that to me. And it's about these outliers with performers. That how do we predict the folks who are really going to be the stellar performers, this those star performers? And they talk a lot about how folks got it wrong. How Tom Brady, Steph Curry, like these uh incredible world-class athletes, you know, among the best who have ever played their respective games. And uh even business leaders, you you when you say it helps to be educated, helps to be smart, but at the same time, when you look at the the CEOs of Amazon and Meta and Tesla, and you look at these folks like oh, they dropped out of college or didn't go to college, and so defy those assumptions that we have about what leads to success. And I don't have any real conclusions to to bring just yet. I'm only about halfway through the books, but it is it is interesting in thinking about thinking about them and how do we when we look at somebody and we're like gonna be a good resident? Or you're gonna like what how do we find those predictors? So that's what I'm in.

SPEAKER_00 54:55

Great, interesting. All right. Well, thanks everybody for listening to this episode, and we'll catch you in the next one.

SPEAKER_02 55:03

Thank you.