04: sangfroid- bringing cool to chaos with

Dan dworkis md-phd

Sangfroid. Literally: "cold blooded," it' the ability to stay calm under pressure. In this episode, I talk about Sangfroid not as an innate talent but as a skill that each of us can develop, and about several ways we can start training sangfroid today.

Many non-crucial details of emergency medical cases, like when a case happened or the age or gender of the patient, have been changed randomly to preserve patient confidentiality. As always with the Emergency Mind Podcast, the goal is not to provide medical advice or commentary on medical care, but to explore best practices and ways that we can all improve how we think during an emergency and apply knowledge under pressure. Additionally, the views expressed on the podcast are personal views and do not represent the views of the employers or organizations at which we work.

03:15— Actually, they were not “dying,” they were dead. Their heart had stopped, and the team was trying to bring them back. I was performing bag-valve-mask ventilation which is a standard and critically important technique of breathing for an unconscious or unresponsive patient. (Dr. Scott Weingart of EMCrit has a deeply technical and interesting breakdown of BVM ventilation here.) A common mistake among early career providers is to get unnecessarily excited while performing BVM ventilation and ventilate the patient too quickly. In this case, that’s exactly the mistake I was making and what struck me was that this other doctor had enough mental presence and field control to not only successfully run the major building blocks of a critical resuscitation but also calmly succeed at the smaller details, like slowing down my breathing cadence.

04:08—I wouldn’t claim for a moment to be anything other than a beginner at Brazilian Jiu Jitsu, but the importance of staying calm and collected during a roll (match) is hard to overstate. There are many great article about this (see for example here, here, and here) and it will continue to be a focus of the podcast moving forward.


04:30— Thanks go to my excellent friend Jon Stenstrom (Instagram @jonstenstrom) from Cast and Spear (instagram @castandspear), both for taking me spear fishing and for sharing this story.

10:10—The purpose of this is not to say that all superheroes come from radioactive spiders (see for example, this) but rather that there’s a significant myth that sangfroid is given to use by something outside of ourselves. The opposite, in some sense, of this idea is well described in the parable by Joshua Medcalf, Chop Wood Carry Water: How to Fall in Love with the Process of Becoming Great. .

10:50—The stonecutter idea comes from the writer Jacob Riis, and is featured heavily in a number of stories including Pound the Stone by Joshua Medcalf.

14:45—As I mentioned in the notes for Episode 03, Peak: Secrets from the New Science of Expertise is an excellent book by Anders Ericsson and Robert Pool about training and developing expertise. It is really, really good, and changed a lot of my thoughts about how I personally train, both in emergency medicine and in jiu jitsu. I first heard about it as an excellent episode of the EMCrit podcast, which can be found here. The quote I use here is from Chapter 1, page 18, and it absolutely is a sobering thought.

18:31—The build measure learn cycle I talk about here is useful in a wide variety of contexts. I first encountered it from the book The Lean Startup by Eric Reis. Equally important in this is the book Thinking in Bets, by professional poker player Annie Duke. In Thinking in Bets, Duke talks about how to determine how much of the outcome of the case was related to your actions and choices, and how much was related to chance. She calls this process “fielding,” and I think it is really important as we continue to build our abilities to think under pressure.

22:45—The moment right before a critical case comes in can set the tone for the team’s response and is a crucial time to perform under pressure. It’s a moment I think about a lot and drill extensively. For more on this, check out the article I wrote for Forge entitled “How to Mentally Prepare for a Crisis Like an ER Doctor.”

25:56—We go into battle breathing a bit more during Episode 03, right around 39:50.

28:08—There are a lot of similarities between this technique (saying a phrase) and the physical anchor technique discussed right before. In both cases, a key underlying point is that the actions or phrases we use need to be worked out ahead of time and practiced. Simply moving our hands in a certain way does not accomplish much—instead it’s the time and mental energy we invest ahead of time in imbuing the motion with a certain meaning that allows us to use it when things are not going well. Ultimately, that is why the choice of movement or phrase is a personal one. It is up to you to find what resonates for you.

29:00—The motivational speaker and author Tony Robbins has a lot to say about the idea of Transformational Vocabulary, which refers to the idea that the words which we use to describe a situation. In his article “Change your words, change your life,” he describes the difference between saying “I’m angry” or “I’m furious” and “I’m peeved.” It might sound like a small point, but Mr. Robbin’s idea (which I strongly agree with) is that investing situations with unnecessary and unhelpful emotional energy can detract substantially from our ability to function at the top of our game. “This is terrible, everything is falling apart,” produces a distinctly different set of emotions and responses—both in you and in your team—than a more cautiously and correctly worded “this is suboptimal.” I’m still working on this, and there’s a lot to learn here about how our word choices affect our ability to think during an emergency.

30:26—There’s a Buddhist parable about the Buddha and a sitar player (in some versions it’s a lute player) which really captures the idea of not too tight, not too loose that we strive for when responding to an emergency. It’s a quick read and a good story. I won’t ruin the ending, but the point is that not too tight, not too loose is the way to go.

35:29—How are you going to practice Sangfroid today? This week? Reach out and let us know!.