Composure Under Pressure: Dr. Joe Nemeth on Mastering Chaos

Imagine

uh if you will a trauma bay where um a

patient who was just shot in the chest

has been resuscitated and you see what

looks like organized chaos. You see

blood on the floor sometimes a lot of

blood. You see instruments, bloody

instruments. You might see a nurse

that's crying of course right

>> and of course family members. And I

think that organized chaos is where

people who know what they're doing earn

their keep. How do you take control of

the room and your mind when it counts?

>> I will answer that question, but I'm

going to say something that you're not

even aware of. Are you ready? You're

sitting down.

>> In this episode of the Strong Podcast,

we enter the trauma bay where

leadership composure and

decisionmaking collide under the

harshest pressure. Dr. Joe Nameoth is an

emergency physician, trauma team leader,

and associate professor at McGill

University. He's led countless life and

death moments at the Montreal General

and Children's Hospitals while building

the training systems that prepare others

to do the same. We explore what it takes

to stay clear when seconds decide

survival. How leaders take control of

chaos without losing focus. How teams

manage cognitive load under uncertainty.

and what medicine teaches us about

resilience, adaptability, and trust when

every move matters. This is an inside

look at performance under pressure

through the eyes of someone who's lived

it. Before we dive in, don't forget to

like and subscribe to keep learning from

the experts who keep us sharp,

resilient, and ready when it counts. Dr.

Joe Nameoth, it's a genuine pleasure to

have you here on the Strong Link

podcast. I'm very much looking forward

to jumping into this talk together.

>> So am I. Big time.

>> Let's go for it.

>> Fantastic. So I' I'd like to start here.

In trauma care, every second, every

decision can change an outcome. How do

you take control of the room and your

mind when it counts?

>> Um, I will answer that question, but

this is all impromptu. I'm going to say

something that you're not even aware of.

>> Amazing. Let's do it.

>> Um, are you ready? You're sitting down.

>> I'm primed. I'm primed.

>> Sounds good. Let's do it.

>> So, listen. I'd like to give two kudos

to you.

>> Oh, amazing.

>> I think um um it's I I'm speaking for

the medical field. Uh we're very easy,

very quick to critique.

>> Mhm.

>> But very slow to uh congratulate and pat

people in the back. I think you've

interviewed and your in your experience

too, I'm pretty sure it's the same

>> uh with the people you've interviewed.

Um for some reason, high achievers um do

not like to congratulate others. There

are some exceptions, but I'd like to do

that now.

>> I appreciate

>> on two two counts. Number one,

>> um I've looked at all your your your

product, what you put out here, and it's

incredible. I think it's a it's very

useful for people uh in my sphere, but

in in any other u industry uh and

frankly even a stay-at-home mom, just to

u to to talk about and the importance of

of how you manage stress and cognitive

load and and get different perspectives.

So I applaud you for that.

>> Appreciate that.

>> And on the second note, I applaud you

for getting a little bit out of your

comfort zone in that um uh you picked me

uh uh somebody who is not uh in the

business field uh is not in you know in

in the uh the military field and I think

that's going out of out of your way a

little bit and you're taking a chance

and I appreciate that. But I I'm pretty

sure I have a lot to offer.

>> Absolutely. And I thank you very much

and you're absolutely right. you know,

taking that moment to step back is

something that we always seem to miss in

the high performance world, but I I

think it also speaks to that earned

wisdom that you bring to the plate, and

I can't wait to unpack that.

>> Perfect. Perfect. And and before I

answer your question, um I think it also

helps with uh with cognitive load and

and how to minimize and mitigate the

stresses, meaning um somebody who's

supportive and who pats you on the back.

That helps. But we'll talk about the

>> Sure. Yeah. So imagine uh if you will a

trauma bay or we call it a recess bay or

trauma room where um a patient who was

just shot in the chest

>> Mhm.

>> has been resuscitated for 10, 20, 30

minutes, 60 minutes and the room is

empty now and you see what looks like

organized chaos. You see blood on the

floor,

>> sometimes a lot of blood,

>> right?

>> You see instruments, bloody instruments.

You might see a nurse that's crying,

>> of course, right?

>> And of course, family members. And I

think uh that sort of um that organized

chaos is where where people who know

what they're doing um uh earn their

keep.

>> Mhm.

>> So, how to take control of room? We'll

probably talk about that and nuance that

a little bit later, but really uh for me

it's uh it's um organizing yourself

first, your team, your environment, and

how you do that. Um uh there are

different strategies which we will

discuss but really it all falls under

the umbrella of crisis resource

management which I'm pretty sure you're

aware of. Um it comes from the aviation

field and of course the military uses as

well. It actually CRM sort of acronym is

really crew resource management but we

we took it over to crisis resource

management. And the whole idea of this

is there many levels but the whole idea

here is that um you

role delegate. You anticipate problems

that might arise. You um uh you you walk

that fine line between sort of directive

leadership and empowering leadership.

And we'll talk about that in a in a few

minutes what that means. uh

communication confidence tone

mannerisms,

>> how you stand, incredibly important.

>> Okay.

>> Um and then we can talk an hour about

communication styles of closed loop and

and how you close that loop when you

>> ask for something or you want something

to be done, how that is done. And we'll

talk about that later. Um, also in this

chaos, organized chaos, regularly

sharing um, your shared mental model of

where things are at with the patient and

where we're going with it,

>> delegating tasks, making um, creating

micro teams so that you as the team

leader are not overwhelmed.

and re reminding yourself in this

organized chaos is you can never not

afford to take your foot off the pedal

because trauma is a dynamic entity.

>> It's not a neurosurgeon, God bless them,

but standing over a patient for 10

hours, um I could never do that.

>> Trauma is a dynamic process where a

patient can come in walking and talking

to you and in a minute be in cardiac

arrest. And keeping that in mind, uh you

have to uh make the decision. So that's

sort of how I see, you know, taking

control of that that organized chaos.

>> Okay. So, a lot to unpack, but I think

you brought up something really

interesting that resonated with me, and

I' I'd like to kind of take a step back

and ask you about this. So, this tie to

aviation, you know, the the crew

resource management model, a derivative

of the human factors piece. And I

remember this was a science that came

out of NASA really in the 70s once we

were looking at the accident and

incident rate in aviation and how it

wasn't uh reducing at a certain point

and they had seen that the technology

had kind of gotten to a pretty safe

point. So it wasn't the technological

component but it was the human

component. And I'm wondering when we're

looking at crisis resource management

and how you've seen it kind of evolve

over the past few years. Are you seeing

the same kind of effect, it was at some

point an indicator where we need to look

at those micro teams very similar to a

pilot co-pilot engagement or a fire team

within the military. And I'm I'm curious

about that context. When did this focus

on the human crisis resource management

really come to the to the light? What

would you say? Um, I'll answer you in a

second, but if I could nuance um uh your

description that it comes from NASA, I

would argue it comes from the Canary

Islands.

>> Um, interesting. And I'll explain to you

what I mean. Uh, the biggest aviation

disaster um happened in one of the

islands in the Canary Islands in in the

late '7s. Two jumbo jets um collided and

I think there was over 500 people who

died and I think it still goes down as

the the biggest aviation disaster. Is

that the one on the on the runway?

>> That's correct. That's correct. That's

correct. Uh for those that don't know,

you should take a look at there's a many

videos on this

>> and and I completely agree with you that

up until there people were looking at

the wrong thing. when people when when

planes were crashing uh they were

looking at at uh at the technology but

where this um incident happened they

actually looked at the fact of human

factors

>> and they identified that this was could

have been all avoided

>> if uh the pilot

>> the pilots and the tower communicated

properly. There was absolutely horrible

communication, closed loop, there was

nothing checklist.

>> And because of that disaster, uh the

aviation industry looked at how they can

mitigate these these these these

potential errors.

>> And if you look at the chart of how from

that point on how uh the incidence of

crashes decreased exponentially and it's

I think it all has to do with the fact

that this is um this is looking at human

factors. Now uh with regards to your

question in in my domain

>> Mhm.

>> Um the er what do you think the error

rate uh is in the emergency department?

And by error error rate I mean a

misdiagnosis. Do you think it's u 50/50?

Well I guess depends on the physician

but is it is it is it is it 25% is it

like less than 1%. What do you think the

error rate is? So I would say and this

is me as a potential patient and where I

would hope right hope the uh the system

is I want to hope it's within single

digits or less or percentage of a

percent ideally

>> um that would be my hope

>> so so um it's about 10 to 15%.

>> Okay.

>> Now when we started looking at that and

and initially we didn't look at it the

right way. So in the aviation industry,

if a plane crashes, the question is what

happened?

>> Mhm.

>> In our industry up until recently, if a

patient died, we have what's called

morbidity and mortality rounds where the

the physician is put on the spot like

this.

>> Okay?

>> I mean, I'm I'm dramatizing it a little

bit, but really it's a fingerpointing

exercise.

>> And that's the wrong way to look at it.

So in our field, it was like what what

did the physician do wrong? As opposed

to let's look at this systematically.

And that's what's currently taking

place.

>> Yes. Yes. It's it's so so getting back

to the error rate that 15% um we looked

at that and there's some good literature

on this that the majority of the errors

are not made because of lack of

knowledge. Like people if you look at um

uh literature on on um on who gets sued

and what are the reasons there's medical

legal there's litigation against the

physician. It's it's rare. I'm not

saying it never happens. is really

because um the physician did not know uh

that this drug was needed for this. It

was more of communication how they

process information very closely tied to

cognitive load and if they're overloaded

their decision-map capability

disintegrates and we'll talk about that

later. So that's that's how we look at

it.

>> Wow. So you're saying the the

contribution of cognitive load and 15%

is not a small number you know

especially when we're talking this is a

mortality or sorry not a mortality rate

error. diagnosing error

>> diagnosing error rate. So, and of

course, every error in diagnosing is

going to trigger another cycle, another

decision cycle. It could.

>> So, I that's even a bit more wasted time

that could go into uh resolving the

situation. So,

>> what we were saying is you're looking at

the human component, the cognitive

decision making. Would you say that

that's the main outcome that's really

the contributing factor?

>> Absolutely. Absolutely. And that is um

is influenced by many stressors. um

whether it's it's what you bring into

your shift that means at home right

>> and we will talk about mindfulness and

peace and contentment that's so

incredibly important

>> and all the stressors that that are in

uh that are I was going to say intuitive

not intuitive but interior to the room

so the patient brings in their whole set

of complexities right

>> um you know uh a patient can come in

with a with an itchy scalp and it could

be something horrible right so we always

uh we we're always on edge as to what

what this seemingly uh you know easy

case could become very very difficult.

So yes, so this cognitive load uh that

you bring in definitely and there's

great uh psych psychological um

literature on this

>> um that it definitely influences your

decision-m activity. If I may

>> uh the marketing industry

>> takes it takes advantage of this. I'll

give you an example.

So, um, when you go to the I'm not going

to mention which whatever grocery store.

>> Sure.

>> Can I swear here or no?

>> You know what? I'm not sure. Go for it.

Let's just do it. Let's go for it.

>> So, when you get to the the counter or

to pay

>> Mhm.

>> the is there. Meaning what?

>> The stupid newspapers, National Enquir.

It used to be at least,

>> uh, the candy, the gum.

>> Right.

>> The whole idea here is that, um, they've

cognitively loaded you ready when you

walk through the aisles. 100 million

cereal boxes, uh, you know, this kind of

milk, that kind of cheese, you're coming

to the to the to the end to pay and

you're cognitively overloaded. And

whether you agree, you admit or not,

your decision-m ability has gone down

the drain.

>> Sure.

>> And and a lot of people would push back

on that, but there's great literature on

this. And so they know this. And so you

if they were to put those stupid things

in the front, you're walking past them.

You're not going you're not going to buy

the candy bar. you're not going to buy

National Inquir,

>> right?

>> Uh but here

>> you will. And that's that's that's an

example of how cognitive load uh weighs

in on how you make decisions. Now

imagine that in treating you with chest

pain,

>> right? And if I were to that specific

mechanism, that point cognitive load is

exhausted. You're going to the grocery

store, you're getting to the end. What

is the condition that's making me choose

that sugary treat at that point versus

in the beginning? that I'm just looking

to reduce the stress from the cognitive

load. I'm looking for a quick fix.

>> No, no, no. I I don't think it has to

anything to do with the fact that I'm

I'm uh I'm hypoglycemic, low blood

sugar, because you're not. You're not.

>> It's more that you're you're you have in

front of you decisions you have to make,

buy or not buy, and what am I buying?

>> And now uh that part of your brain that

usually manages this is overloaded.

>> Okay. Okay. And and there's some some

great I'll give you another example who

who takes it a couple of of um of

studies that looked at this. So they

looked at um a parole board,

>> okay?

>> And um they looked at uh you know

prisoners that are going up for parole

and they want to be they want to be set

free, right? So the parole board meets

with them and they looked at decisions

of the parole boards that if you as a

prisoner come in for a parole meeting in

the beginning of the day, you're more

likely to be let loose than if you come

at the end. Why?

>> The thinking is that by the end the

parole members cognitively overloaded.

They they are done and for them the

default is no.

>> And so there's that. And there's some

evidence for that uh very briefly in

medicine as well. uh many but I'll give

you an example. Uh they looked at a

bunch of family physicians who um who

saw patients and the patient came in

with a viral illness,

>> a runny nose cough. And if they came in

earlier on, they will not get

antibiotics. They'll they'll the

physician will take time and explain

that you don't need this antibiotic,

sir. But if they came in at the end of

the day, much more likely to get an

antibiotic. So these are examples of how

um cognitive load weighs in on your

decision.

>> Yeah, I'm Does that make sense?

>> Yeah, absolutely. as you're talking,

it's it's reminding me of examples even

in aerospace shift work. So, making

these critical decisions in the

afternoon or evening shift or even just

the the military side of things when

you're operating at night purposely

pushing through sleep. So, I can't wait

to to dive into that. If I take a a

second first for you and your story,

what I'd really like to do is take a

second and ask you what first drew you

into emergency medicine, trauma

leadership, and what keeps you there?

you're very uh energetic and clearly

passionate about the topic. So I'd like

to know the why behind that and where

that started.

>> Um I'll premise my answer with a couple

of things and I think credibility is

big, right? So so why should uh anybody

on this podcast look listen to me or or

even take my advice or take my not my

advice but what I say. Um look, I have

28 years of emergency medicine

experience. Um and I broken this down. I

did this this mental exercise recently.

So that equates to approximately almost

7,000 shifts of 8 to 10 hours

>> and that equates to approximately

160,000 patients that I've seen. Okay.

So approximate.

>> Sure. Of course.

>> So

>> I I have a little bit of experience. So

that's number one.

>> So getting back to your question u why

emergency medicine? So there's a sort of

an algorithm a flowchart of sorts for

for phys for for medical students to uh

decide what they want to do. It's it's a

little bit uh facitious but it sort of

makes sense. So in the in the top you

have um medical student are are you

crazy or are you sane? Okay.

>> If you're crazy you're going to go

either into emergency medicine or psych

psychiatry. Okay. And then and then when

you say you're crazy do you have an

attention span. If you don't it's

emergency medicine. If you have an

attention span is psychiatry.

>> So that sort of gives you an idea.

>> So this is this is mapping well with

you. Perfect. Perfect. If you talk to my

wife she was right here. She would say

the same thing. He's crazy and he has no

attention.

All right. So, so um um I think um when

an when a medical student asks me like,

you know, should I go into emergency

medicine or not? My what I tell them is

you definitely need um emotional EQ. You

need you need EQ. Okay. Uh so if you're

if you're one that um is very um um you

compartmentalize things and you know

this is this then I'm going to go into

that. That doesn't work in emergency

medicine. So you might see in one minute

you might see a patient who has an itchy

scalp for 5 years and you have to

explain to them that it's probably not

an emergency and the next in the next

minute you might have to tell a wife

that her husband was killed by a car and

and uh so you need that EQ right um and

I don't think other

>> other disciplines and I don't want to

minimize and I don't I don't disrespect

other disciplines but to the to the

extent that we need it I think I think

it's pretty one of the significant right

>> absolutely Um we need to be uh

inventive, efficient with our time and

our efforts. We need to be energetic of

course um friendly, confident, but not

in extreme cases because if you're

overly confident, you get very

dangerous.

>> If you're too cautious, that makes you a

horrible emergency medicine physician as

well because you need to be able to move

people,

get a disposition on people. So, a

patient comes in, I have a certain time

frame to make sure they're not dying.

>> And then I have a certain time frame to

um uh to make sure that they get the

right treatment by the right physician

and get them out of my department as

soon as possible if they so you need to

be you need to have both of those

things. Now, that's emergency medicine.

Why trauma? Well, trauma just takes it

to another level.

>> Actually, if for this for the viewers,

how would you define emergency medicine

and trauma? What distinguishes those

two? It looks like you're reading my

because exactly that was my I was going

to I was going to explain to you. So

>> just for for people who don't know um

this the field of emergency medicine um

means that you're taking care of uh um

of patients coming in with an acute

injury or illness.

>> So that could be a gunshot to the to the

head or it could be a heart attack or it

could be an itchy scalp. M

>> so what happens now is that we've our

field has become very super specialized

in that there's in in under emergency

medicine there are different subsp

specialties and one of them is trauma

>> that doesn't mean that a general

emergency medicine physician cannot take

care of a trauma patient but there are

now people who have trained and are

passionate about trauma

>> uh that take it to another level and

they're called trauma team leaders in

fact uh I will proudly say that in in uh

we developed in Miguel the first trauma

team leader paradigm as it were in 2005

>> there um and the whole idea here is that

in in the field of trauma trauma

surgeons ruled so the surgeons ruled um

uh with the resuscitation and of course

when the patient goes up to get surgery

it's the trauma surgeon that that deals

with that this whole trauma team leader

paradigm started by saying listen emerge

docs uh who with special training can

resuscitate the patient meaning the

acute care issues of of taking care So

the patient doesn't die in the first 15,

20 minutes, 30 minutes. We can do the

same as surgeons. And so that's what I

mean by a trauma doctor as such. So I'm

one of the trauma team leaders that

takes care of these kind of things. Does

that is that clear?

>> That's clear. Yeah, that clarifies it.

>> And so and and then why what keeps me

there is that that that desire and I

think I speak for most most of my

colleagues that desire to make an

immediate impact um and significant

impact on pat on a patient's uh status

especially if they come in very ill. uh

the variety, the the fast-paced nature

of of our of our business, uh

unpredictable, the unpredictability, the

environment that's that's often times

very chaotic. Uh and a blend of all

those things, uh teamwork, you need to

be a team player. So all of those

things, I think if you were to uh if if

I were to rely up 10 of my colleagues,

they would say the same thing. These

were these would be the the things that

keep us there and then make us love u

love what we do.

>> Okay. I keep thinking of three words

when I was listening to that description

and it it seems like the effect you're

looking to scale and and enable

consistently is that capable, adaptable

and uh ready team to manage those

different environments. That's a that's

a state of readiness which is that takes

effort and testing and retesting and

revalidation. So uh it certainly seems

um like a huge undertaking to be honest.

So

>> it speaks to that earned wisdom. So I'd

like to pull on that. How do you define

performance under pressure after decade

of leading these trauma teams?

>> Um

this too we could talk about for for a

long time, but really uh the ability to

uh to maintain situational awareness uh

where you you know when to step back and

wait versus when to act right away. uh

prioritizing life-threatening issues um

and decisively making executing that

plan. Once again, a continuous um shared

mental model incredibly important so

that the team around you uh who is

looking to you for team leadership

understand where your mind is at with

the with the case and what my what as a

team leader uh concerns are in the next

few minutes. So that shared mental model

that has to be almost seamless and

continuous and not intuitive. So not uh

not thought that it's it's it's it's

everybody's aware. You have to make that

a conscious and and active effort to to

share that uh clear communication uh

role clarity is incredibly important and

you'll see I think I'm going to say it

often that that communication is so so

important that closed loop

communication. Maybe I'll take a time a

little bit of time to uh to explain what

that what that means is. So um if I if I

have a patient who is uh actively dying

in front of me and they have a u um

heart attack uh and and I tell nurse A

nurse A uh no if I say can someone give

this patient this medication

>> that is horrible communication skills

because someone is no one

>> sure it's not precise enough

>> someone is no no one and this brings up

the whole idea of of of the aviation

industry as well and if you look at that

that video of that those two planes

crashing and a lot of it was this right.

So what what should happen is the

following. Nurse A, call her by her

name, whatever, can you please give this

medication

once you give it, please let me know. So

it's not a question of only telling her

do it, but telling her to feed it back

to me that it's done.

>> Incredibly important. And and it's a

it's it seems very minimal and nuanced,

but it's an incredibly important nuance.

So that's what closed loop communication

means. And that's part of performing

under pressure. Another thing that's

very important in performing under

pressure is avoiding tunnel vision. And

and and uh that's why the team leader

has to be as as handsoff as possible of

the patient. So as a as a trauma team

leader, I'm able to do all of the

procedures that need to be done. Like

just to give me an example, we sometimes

are called to open up a chest to um to u

to arrest a bleeding from a heart that's

been punctured by a a missile, an in

whatever. And so so we we are called to

fairly high level of procedures. Uh but

we we as team team leaders should never

do that. We should have the whole

picture in mind, the the for the forest,

not just the tree. And if you start

getting involved in a in in somebody's

um procedures, you get tunnel vision

because that's all you're seeing. So a

good person who performs under pressure

is one that does not fall that into that

cognitive error of tunnel vision.

>> Staying calm, thinking ahead with

contingency plans and adapting to

shifting priorities. I think these are

the main things that are important.

>> Yeah. So I I pulled a lot from that and

I really like the the closed loop uh

approach and trying to avoid that that

tunnel vision. Can you take a second to

expand on what you mean by an explicit

mental model that's shared collectively

with the team?

>> Yeah. So, uh what we say is um every

five take five. So, what that means is

that not necessarily five minutes but

every on a regular basis during a

resuscitation you should take

an amount of time to share what's

happening. So what we usually say is

that patient comes in early on, you do

the initial potential reversible life

condition um threatening uh issues and

you deal with them and then you stop.

Okay. So let's see what we have now. So

patient came in with XYZ. This is what

we did. Now we're going on

>> potentially this could happen. This

could happen. Then we do another set of

resuscitation measures. Then we stop

again.

>> There's no time set. There's nobody

counting on a clock. Okay, Joe, it's

another five minutes you have to take.

It's it's also intuitive in for a good

time leader to know when to make those

those those those stops and and and and

share uh explicitly with with the team

members what I'm thinking of and where

we're going.

>> Well, so that's really interesting. So,

in this situation, which is a crisis

moment and you're you're dealing with

it, pumping the brakes or taking a short

pause at the right moment, but

collectively speaking out loud, okay,

this is the current state. This is what

we see. what are some options? Okay,

let's keep going. And then actively

introducing those pauses in that crisis

act state.

>> If I could interject one more thing with

these pauses and I I make this very

explicit before the patient comes in is

that number one um I make mistakes. So

when in during those pauses I will say

often, okay guys, am I missing anything?

Okay,

>> incredibly important and to empower your

team

>> not to feel intimidated that here's the,

you know, high and mighty. No, that's

number one. And number two, to give you

an example, what I mean by that is that

I empower the team if they see something

that's critical to interject at any

time. So, we h we have a um sort of a

call out thing saying

>> critical finding and I have no problems

with even a med student. I was going to

say a lowly med student. I was a lone

mess so I can say it but but anybody in

the team saying critical finding

>> and and I'll stop and then so and of

course it's understood it's not critical

finding that the patient's shoes are

undone right it's something so these are

just examples of how you have to stay

humble

>> uh empower your team to feed things back

to you whether it's it's on a regular

basis or at any critical time

>> I it's just it's really sticks out to me

you know I was introduced to immediate

actions and these immediate reactions

you'll do when you're under fire or

dealing with the situation within the

military. But I've and we have our

communication drills and everyone's

doing their particular actions. But to

hear and it is comforting to be honest

these check and balances happening in

real time with members who may see a

critical failure point and be able to be

empowered to interject and that constant

re-evaluation realignment during a

critical state because I've I've seen

it. I've rehearsed it where you can be

triggered with an immediate action and

you can immediately derail and get into

the wrong course of action. So, this is

really interesting to pull from that.

You've you've spoken about cognitive

load or adaptive cognitive load. What

does that mean, especially for someone

who's never really heard that term and

how does it affect decision-m when time

and clarity are limited?

>> Sure. I think before we talk about

adaptive uh sort of cognitive load or

how you do that. So what is cognitive

load? Uh it's it's the amount of sort of

working memory or knowledge base that

you have at any one time that is

available for your uh you you're using.

So, so um um you know uh I think that's

the best way I can I can sort of uh uh I

can I can sort of um uh explain it is is

is that uh at any one point when you

have to make a decision uh based on your

experience and your knowledge of that

situation you have to make a decision

that's your cognitive load there really

it's what it is um Ashan is is to

maximize signal to noise ratio

>> um so signal is the permanent positives

and negatives of a case and noise is

everything that's not

>> and a good clinician and I'm not saying

just a trauma doctor but an emerg and

I've stressed this to the trainees is

that if you can weed out the noise

you're that much better so um so when

people when a med student askked me well

Dr. What's a noise? Well, noise is

patient's favorite color. I really don't

care about that. I'm just using it as a

facicious example of course. But but

noise is is things that are not

contextual. And if you can maximize that

signal which is the permanent positives

and the noise that ratio that's better

physician you are. So the way you I

think of adaptive cognitive load

is uh are you a treky start?

>> Of course. Of course. Absolutely.

>> It was a rhetorical question. I knew you

were.

>> Sure. Of course. So, um, but the old

ones, the real ones, the real. Okay. So,

you know, Spock.

>> Yeah.

>> Kirk.

>> So, for those of you that you should, we

should watch a couple of series.

Phenomenal that it broke so many

barriers. Incredible. It's I don't

remember who the director was.

Incredible. Uh, anyways, so the whole

idea here is that I think I think that's

a beautiful example of adaptive

cognitive load where

>> Kirk is off the cuff,

>> what we call huristic uh thinking. um

experience uh pattern recognition, not

thinking.

>> Mhm.

>> Not thinking, thinking but not thinking.

>> Sure.

>> And then of course, if you know the

series, Spock is that analytical uh very

thoughtout person,

>> right?

>> In emergency medicine, the extremes of

both are dangerous.

>> In incre a good emerge doc walks that

fine line.

>> Do you play chess?

>> I do.

>> Okay. So, if I tell you uh Gary

Kasparov, does that ring a bell? No. So

it's before your time. He was a

grandmaster for look him up for 30 years

>> and um I I give a talk on this uh many

platforms and I pick a I put a picture

of him up where he's he's he's playing

simultaneously 30 different games with

30 chess masters and he has like a

minute to go from one to another and

then comes back and I think that's a

beautiful example of systems one and so

of of this fast thinking and this low

slow thinking and I was going to say

system one systems two it's just another

way of saying this this different ways

of thinking thinking. So systems one is

the fast off-the-cuff experience uh

generated knowledge and systems two is

like the spock which is uh which is very

analytical. So this guy goes from one

checkboard to another and is is using

his experience to make fairly quick

decisions but yes he's still analytical.

I think that's the best way to think of

adaptive cognitive load. Does that make

sense? It it does and it's it's

interesting because it resonates with uh

another speaker we had um and uh Brian

he was a US Ranger and he talked about

this ability where you need to be able

it's a muscle too but he talks about

selective focus right if you're doing a

particular operation or you're at work

or you're coming home that it was highly

beneficial to have this muscle where you

selectively focus and then move out so

it seems a very similar approaching

tube. Yeah. And we talked about the

adaptive uh cognitive load. I really

like this

>> signal to noise ratio and that's a

skill. That's an ability. It's probably

a learned ability with experience.

>> Um I wanted to ask you about so

bandwidth. So let's however it's defined

and measured but is it is it possible uh

to even increase our bandwidth when it

comes to cognitive load so we can take

on more and then be better at that

signal noise ratio piece. After every

question, I always want to say great

question, but I'm not going to because

it's just going to sound but this is

another great question. Um, so

>> yes, the answer is yes. And I think this

goes back to uh signal to noise. I think

um you can increase your bandwidth for

important things in uh what you're doing

high stress things if you minimize the

noise. And there are many techniques to

do this. Um uh you can delegate tasks,

you can form micro teams to take care of

stuff that so you don't have to worry

about that.

>> Um there and we'll talk about this I

think later but uh the way you uh you um

uh you use breathing techniques and and

how you um how you self-talk and certain

things that how you do within yourself,

how you prepare yourself. Of course

knowing your stuff is incredibly

important. Like we can talk about this

all I want, but if I have no idea or I

have very little knowledge of how to

take care of a patient, this is nice,

right? It's the classic Mike Tyson who

says, you know, we all have a plan until

you're punched in the face, right? The

same thing here. This is sounds

beautiful, but if you have no idea how

to take care of a a heart attack or

somebody uh you know, uh you know,

whatever pick your poison, then this is

just uh BS, right? So So knowing your

stuff is very important. So that's sort

of how I how I I handle or increase my

bandwidth as it were.

>> Okay. Okay.

>> Is that is that okay?

>> It does. And I I we're talking about

self-development skills. We're talking

about honing it. And I think it builds

into um the work you're doing at uh at

McGill. For example, you've built

simulation and fellowship programs at

McGill. How do you design that training

which replicates the mental chaos that

we're speaking about that we find in in

real emergencies? Um so I think once

again I I have I'm I'm going to bring

this up again but the that that that uh

that the aviation industry has given us

uh like we stole everything from the

aviation industry uh in medicine. In

fact if you look at um simulation

medicine uh who has really taken a

forefront in this is the anesthesia

world. The anesthetists have done a

great job. If you look at literature a

lot of the literature comes from

anesthesia about stimulation medicine.

Uh I'm not quite sure why uh but it it

is the it is. So emerge is lagging

behind but we are. So what we do is uh

we we especially in emerge we we try to

uh uh uh create simulation where we

replicate that mental chaos of real

emergencies or trauma. Right? So that

could involve using highfidelity

scenarios. So using very highfidelity um

mannequins that can give feedback to

you. Uh there's even virtual reality now

that you can use and and AI as well and

and artificial reality as well that that

mimic the unpredictability of a

physiology of a patient that's very

sick. Um there's the other thing we

introduce in these kind of simulations

is controlled distractions. So uh we we

have um uh we have alarms that go off

out of the bullblue multitasking

demands. unexpected family member runs

in and and is and is and we have

actually these simulated patients that

are actually the you know actors that

come in and are trained for this and

they they simulate that that that whole

drama and this is how we try where we we

we we

train our trainees with that team

dynamics. We we definitely try to have

simulations where there's

interprofessional um uh uh sort of

involvement. So it's not just physicians

training physicians, there are nurses,

uh different healthcare providers that

are in this team and that that also

simulates reality as well. Um and then

stress inoculation uh this we took from

the military

>> and I think you know this much more than

I do. Um you know uh and I put this

slide up as well when I give this talk

is look at Navy Seals, right? Uh, Navy

Seals, for those that don't know, are

very high level army um military

personnel that do very high level high

stress things. And it's a whole another

level of of uh military expertise and so

on and so forth. And and they stress

inoculate them. And once again, I'm

speaking preaching to the converted. I

know I know you know this more but I'm

just more for the audience that um for

example um they make them do a 3 km uh

um swim in the ocean and out of nowhere

every so often they have no idea when

>> somebody comes out of the water and

tries to drown them literally. So it's

it's simulated. So they're they're

they're trying to swim. They're trying

to maintain their head above water in

these waves and all of a sudden they

don't know when somebody comes and and

tries to and they have to fight them

away, push them away. There's other

things they do where they wake them up

at 3:00 a.m. out of the blue. They tie

their hands and feet and they throw them

into like 12 foot of water and they have

to be able to float or um monitor their

breathing so that they can stay float.

they can come draw come down and then

push themselves up again, take breaths

and and then do that in the meantime try

to untie their their knots and so on and

so forth. So these are things that are

incredible and this builds and we'll

talk about this a little bit later but

this neuronal plasticity where your your

nerves and your your circuitry are

trained now to handle these things and

and and and then it becomes second

nature. So this is what we try to to

introduce in our simulations as well.

Um, it used to be uh taboo to introduce

death in simulation. Like you just don't

nobody dies in in in in simulation in

emergency medicine and I always thought

that was wrong because that's not real

life. So we're introducing death in you

know and and it could be quite impactful

right so so um so these are the things

that we can do and of course debriefing

uh after a simulation is incredibly

important where we sit down with the

trainees and we discuss what you feel

good about what you didn't feel good

about and we and we talk about not just

the the medical aspects but the

communication and so on and so on

>> right I I mean it it it really resonates

I mean I've done the stress inoculation

within the military but to the medical

field and I think it speaks to the

unique challenges that take place within

medical simulation. We will do stretches

inoculation in different tactical

training scenarios but one of the

toughest scenarios that we purposely try

and train for are mass casualty

situations or casualty evacuations. And

it's really interesting. You talk to an

infantry soldier uh training for uh

reacting to fire or setting an ambush or

uh reacting to an IED situation. There's

a steps from A to Z and we can get

through it and it it's challenging. You

throw in mass casualties when you don't

know what the patient's going to do, if

you're going to make them worse and

you're trying to deal with the

situation. It's a whole different set of

challenges. So I can only I can only

appreciate from a cursory piece how

difficult this must be in terms of what

you're you're looking at enabling. So in

terms of bringing this all together when

you come to the different systems in

place right so what roles do let's say

systems checklists which again is taken

from the the aviation piece as well how

does that go into protecting cognitive

bandwidth and I' I'd like to just frame

this there are leaders I remember in my

time in aerospace who are dealing in

those crisis situations and their

cognitive bandwidth is challenged but

they don't have the benefit of SOP's

check. There's that gap. So, how does

that how does this play a role?

>> So, it's interesting that you bring this

up because we're actually with one of my

uh resuscitation fellows, we're working

on a what we call a Mayday checklist.

>> Oh, interesting. Okay.

>> So, uh once again, we are copycats in

medicine and we we started looking at

checklists many years ago because the

aviation industry worked. It cut down

all the crashes. So, it must work with

us. So, there's checklists for surgeons

have tons of checklist. Is this the

right patient? Yes, check. Mrs. Smith,

is is it an appendecttomy? Yes, check.

Uh, is the patient that So, there's

checklist like this. But as you can

appreciate in a in a very dynamic trauma

scenario or any sick patient,

>> we don't have time for that.

>> Uh, you know, a pilot can sit down

before the flight and do the checklist,

>> but when it's Mayday,

>> they need a different checklist. They

cannot go through five pages. Go ahead.

>> So that was the whole concept of of

developing a Mayday checklist. And we're

doing this for many presentations that

are life-threatening really like a one

pager and I would even say a half pager

where of course you're you're you're

assuming a certain level of competence

for the physician. But if but if this

comes in then I look at it. So I'll give

you an example. So we have um uh cardiac

assist devices that our patients are

walking around with. They're waiting for

our transplants. Okay. It's a um it's a

very rare occurrence that they come in

with very sick, but if it does, we have

to know what to do. And and this brings

up a whole concept of halo

presentations. I I don't know if you

ever heard of that concept. Not halo.

Halo, but halo. So, high acuity, low

occurrence.

>> So, halos are what emerge dogs live for.

>> But we need and getting back to your

your before before question is the

bandwidth. We need we need AIDS because

I'm not going to see um this type of

patient maybe once every six months, but

when they come in really sick and

they're dying in front of me,

>> like I I don't have the knowledge right

now to do what do I do right now? I sort

of have a knowledge, but I don't. So, I

have this Mayday checklist, right? where

okay I I pull it out this this this and

I know so I know I know what's going on

but this reminds me of these are the

steps you have to take right now so the

patient doesn't die once again these are

not for don't don't think that emerge

docs walk around with these mayday

checklists it's for the truly halos the

high acuity low occurrence and it just

gives you another uh cognitive offload

it's a cognitive offload where where I

know that I have in my pocket um the

Mayday checklist and patient comes in

with your run-of-the-mill stuff. So, hey

ho, so high acuity, high occurrence, we

don't care. But the high acuity, low

occurrence ones is the ones that we need

these Mayday checklist for. And that's

how we we mitigate that and that's how

we we help uh each other and and to

cognitively offload,

>> right? I I really like these acronyms

because I it speaks to a challenge which

I even faced myself specifically on

cognitive load. So, hi ho. Oh, sorry.

Ho, let's say it's high. Yeah, exact

high acuity. Hey, high acuity, low

occurrence. Halo halos. And

>> there's low there's there's low accur

I'll give you an example. Low acuty, low

occurrence. Um, dandruff for 5 years.

Like, I don't really care if I I don't

need a checklist for that. Okay. So, um

I'll give you an example of a high

acuity, high occurrence, like somebody

with chest pain or headache. We don't

need a checklist. An emerged doc is

competent. That's why we're merg

of where we see something once every

three or four shifts or three for three

or four months. I think it's it's it's

good that we have these kind of things.

>> Absolutely. So what I found really

interesting is checklists in the use of

it can be paralyzing at the

>> Absolutely. Absolutely.

>> Exactly. Absolutely. And I've lived it

where I was like, so we had to do

different scenario training and and um

competitions and so on within the

military. And I remember very early in

my leadership career was given the

opportunity to try out lead these

patrolling teams and and go on. And I

tried to come up with a checklist for

every possible situation. And then as

>> how long were your checklists?

>> Oh, I could I had pages, pages and

pages, right? And we all we would

laminate them and everything. And I

distinctly remember when I was given the

opportunity to go on one of these uh

scenario events uh which was my first

foray into a complex environment which I

wasn't used to. So complexity was

significant and the checklists didn't

work and I had to resort back to some

sort of default state. We and we

executed. We made it through. But it was

really interesting because we were

working up to the main event and we had

the benefit and privilege of being

coached by some senior members,

reconnaissance members, snipers, uh,

within one of our Regg Force battalions

and they saw the same effect. You know,

someone who wants to do better and is

trying to come up with solutions and

checklist for every scenario. And they

they pulled us aside, put it put their

hand on our shoulder and said, "You

can't plan for every eventuality." But

what you can look at in those moments

where you you can't resort to that

checklist. It always stuck with me was

always try and approach it where you

first eliminate the threat so that it

doesn't get worse. You know, establish

security and then start working the

problem.

>> And that's exactly what the Mayday

checklist is. Right. That's exactly what

they And when they when that 747 drops

20,000 ft, that's when they're not going

to pull out 10 pages, right?

>> Exactly. And and you're right because

even in aviation, it was drilled into

me. Aviate, navigate, and then pilot.

Like, it's it's there. But I like the

distinction between higher currents and

lower currents because in those you know

the the the lower currents points and

the the high uh occur

those critical moments you you need that

checklist and to be able to rehearse

those critical moments. So I think

that's a really a really powerful

takeaway. So building on these high tra

events after a high stakes trauma event

what does recovery actually look like

for you and your team? You talked about

the EQ piece, right? Multiple spikes.

There's a resilience component there

like to pull on.

>> Yeah, there is. U there's some science

behind it as well. Um so when you're

when you're faced with any stress, uh

whether it be a stress of of uh going

into work for the first time for

anything, any stress, it doesn't

obviously doesn't speak to just

medicine, any stress at all. Uh there's

there's a sort of a um an incredibly

wellestablished uh um system that kicks

in um that helps you um navigate and

helps you think for the most part

clearly. It's the sympathetic nervous

system. And so the whole idea here is

that uh whenever you're faced with any

stress, there's a certain set of

hormones that are released. And this and

if it's not over if it's not

overreacting

uh because over too much stress is no

good either obviously um it actually

helps you to um to process information

um uh be alert and so on and so forth.

So uh that's where your heart rate

increases your breathing goes a little

bit faster. In fact, they had some um

there's some literature showing that

there's a there's very uh optimal uh

heart rates uh with stress and I think

some some of this is military where

where if you see if your heart rate goes

above a certain amount and and this too

is very object subjective right like I

both of us are in good shape what's your

resting heart rate 50 probably

>> I wish 50 I would say about 60

>> so so let's say let's say that you go up

to 80 that's already fast for you versus

my wife runs at 80 The average person

runs at 80, right?

>> So, if you go up a little bit, and I'm

not going to give you numbers because

it's useless, your your thinking

process, your your manual skills are

improving. However, if you go too far,

you start shaking, you stop, you start

having tunnel vision, and that's not

good either. So, there's a whole idea of

how um uh I'm going to answer your

question about recovery, but but when

that stress is gone, that patient,

remember I gave you that that that case

in the beginning where that patient the

the room is empty now. uh blood on the

floor, the patient, let's say, made it

that incredible sympathetic discharge

that that those hormones now drop

>> and you're uh and that could be

exhausting and that's why people are

exhausted after something like this and

that needs to be mitigated. So getting

back to more pragmatic uh answer to your

question, if the patient didn't make it,

um I try to um uh have a minute of

silence. Uh I think it's very important

um uh for closure whether you're uh you

know you're spiritual believing God or

not makes no difference. I think that's

important.

>> I think a good debrief with the team uh

not an hour but 5 10 minutes. So how do

you guys feel and that's very important

as well for closure and and and I have a

special one that I deal with with the

trainees and the nurses actually have

their own sort of debriefing. And then

um and then there's actually resources

at the hospital that if you have

problems dealing with this the next day

you have uh you know you start having

nightmares about the patient you can

actually call. So there's resources out

there for you.

>> And then uh last but not least and

definitely not least is speaking to the

family.

>> Okay.

>> And that's part of after the the fact

right now uh you know I'm talking about

if somebody doesn't make it and that is

a whole different level of of of stress

and cognitive load. um where you um you

know um you know you don't do much

talking uh you do a lot of listening

>> and uh and I'm if I continue talking I'm

going to have tears in my eyes because

it's it's it's um it happens doesn't

happen every day but it happens often

enough that that it definitely impacts

what you do. Is this is is this

something you can simulate in in the

simulations you've you've done to to

stress inoculate and it's I don't know

if it's something that can be actually

done in a scenario.

>> Yeah. Like I mentioned to you up until

fairly recently it was a taboo. Nobody

dies in the simulation. Right. So and I

thought that was not good. Right. So I

think I think there are there are

simulations where where you don't go

through the case but this the the day of

simulation is is giving bad news and so

we talk about it and then you go sit

down with the but there's no case right

>> takes away a little bit off the edge

right so we tell people what are what's

the the strategy of going into a room

whether it's a room of a of a parents of

a 5-year-old that was just drowned

versus whatever right uh you know a

90-year-old gentleman who was demented

and stage cancer who dies a little bit

different uh uh dynamics of how you

approach that, right? So, so there is um

there's we we we we teach that but we I

think we need to do a better job.

>> Yeah, it's it's really interesting

because that is one of the aspects we

don't dive into as much. We always think

about those high energy high stress

states. But what about those low energy

high stress states when you're walking

into a very uncomfortable decision? So

really really interesting and I this

also speaks to doing that type of

discussion in a fatigued state

>> in a in a cognitively overloaded state.

Yes,

>> absolutely. And so let's unpack that a

bit more. What practices really help

prevent this long-term cognitive fatigue

or burnout in such an intense

environment?

>> Yeah. So uh I like to think of it as

cognitive capacity e economics. Okay. So

um a bit of psychology literature and um

and you might not believe this uh but

it's true.

>> So every decision you make in life. So

this morning before 8:00 you had to make

a decision on what kind of coffee you

going to have, are you going to brush

your teeth before or after? What are you

going to wear? Uh what are you going to

eat at supper time? So there's a whole

set of of of decisions you make the

first hour of life. By the way, you know

how many decisions we make per day?

about 20,000 the average person and if

you do the math it's almost impossible

because there's not many seconds in that

right so so even if it's half true but

that's that's the literature incredible

decisions but you say Joe yeah but I

mean what socks am I going to wear I

have to make a decision on these socks

thank you but that was a cognitive load

and you say Joe you really no I'm

serious so so the psychology words that

every decision you make even if it's

incredibly small or you think is small

takes away from your capacity for the

whole day. When you wake up, you have a

a a crapload of cognitive capacity.

>> Okay?

>> Every decision takes away from that.

Every decision.

>> I'll give you three examples. Um not

that they're idols of mine, but or I I

respect them, but they're examples. So,

Obama,

>> okay,

>> uh Steve Jobs and uh Zuckerberg. Mhm.

>> If I if I tell you to picture them, what

you Steve Jobs, what what does he wear?

Do you remember black shirt? Exactly.

Zuckerberg

>> and Obama supposedly always wear the

same. They believed in this.

>> So So when they woke up, I don't want to

decide what I'm going to wear,

>> right?

>> Like they were firm believers in this

>> and I think more and more and my wife

and I have have she she knows this

already. She I drill it into her that

that that like for me it's easy. I just

wear scrubs so I don't have to wear but

but if let's say I had to I had to like

this I you know you told me come come

dress appropriately I thought of this

last night last night not this morning I

said I knew I already so that's one less

decision so that's number one so make

sure that you're you're you're

prioritizing your your uh your what

you're thinking of

>> um and then in in your job whatever your

job is um you can always make um uh you

can you can sort replenished your your

cognitive capacity. How? Eating and

drinking. I'm a bad model at this. My my

kids will tell you that I I don't I

drink a lot. Sorry. Drink a lot. But but

I don't eat. But you should.

>> Um humor. Incredible. Okay. Um way of it

can it can increase improve that

cognitive load and and take away that

cognitive overload. Cognitive RNR,

cognitive rest and relaxation. Yes.

Outside of the job you have that as

well. So, hobbies, travel, so on and so

forth. But in the job as well, there's

some good literature and I tell this to

all my traineees before a shift. Every

two to three hours, I want you to do

something for yourself. 5 minutes,

>> Dr. Name, there's maybe we shouldn't

film this. There's so many patients to

be seen. I said, I know, of course,

somebody dying in front of you. No, but

5 minutes is not going to kill anybody.

And I would argue when you come back 5

minutes later, you're that much of a

better physician because you've

rebooted. So, how does that look like?

Uh, what can you do? I always say, "G,

can you give me some examples?" They

always say, "Eat, drink, and bathroom."

I said, "No, those are, of course,

you're going to do them. Do something

else. Jumping jacks, meditate, pray."

Um, if you have a significant other,

call them. I have three kids. I've been

married 31 years. Every every shift, I

call my wife three or four times, and I

text my my my kids once at least. Okay?

>> These are cognitive offloads for me.

It's not I'm not I didn't say this to

pat myself in the back. I'm just telling

you these are things you can do and you

should do. So these are these are

cognitive uh rest and relaxation bands

and of course inner peace and

contentment and mindfulness and and for

me uh uh it starts with that. So um my

uh my Christianity is very important to

me and that's where I take my my inner

peace from my that's sort of number one

and then my family is my number two

thing. So my my relationship with my

wife trumps everything. Um and if that's

not going well

>> it's going to impact me 100%. People

say, "No, it doesn't." It does. At least

it impacts me.

>> And of course, my kids. And then the

rest falls into place.

>> Right. I was just scribbling these down

like crazy. This is uh because it's it's

refreshing to to apply a framework or to

take a look at what can be improved

upon. So, some of the parts that I found

really resonate. So, those decisions we

make every single day. And I've felt it.

You could be exhausted by the time you

hit breakfast or that first coffee

before you even show up at the first

shift. And it reminded me of another

term that I came across when we talk

about this, which was to try to

structure your day where you're

translating the conscious into the

unconscious. Like you said, you picked

your outfit the day before, you're just

going to now put it on, for example. So,

I thought that was very empowering, but

the replenishment piece. So there's a a

concept where you're going to wake up,

get to work at whatever state you're at.

You're going to grind through this and

you're missing so many of these

opportunities to replenish nourish

certainly. But the cognitive offload

piece, there's this preconception that

if you're in a high performance role,

constant chronic stress that you're not

taking the time to spend the time with

the family. multiple touch points with

your wife and your kids throughout the

day as a measure to cognitive offload

and replenish as a sustainment approach.

That's that's uh amazing to hear that

that's even a possibility. So that

really resonated and that inner peace

and contentment side. I can't think of

the number of times you're in a high

performance role, you're focused because

you know the challenges that are going

to come up in that shift, but you come

back home and you may be unsettled

because of how that day went. you were

already pre-imagining what you needed to

do to make it successful. Maybe you

didn't hit that and now you're in this

distressed state. It's hard to sleep.

It's hard to recover. Your mind keeps

reliving it. So, you're not really being

able to dive in and gain that little bit

of inner peace and contentment. So,

finding what that means to you, I think

that's that's really highly highly

resonated. Can I interject there because

you um I wanted to just say that you

said when you come when I come home from

a a tough day and once again this is not

just anybody. It's it's it's it's it's

access accessible to everybody.

>> Uh you need home to be an oasis. It has

to be an oasis for me. I'm coming we

have my my wife and I have two big big

chairs and we call them our thrones. And

the day starts there if I'm not working

and the day starts there in the morning

and the day ends there. So, we sit down

and we talk. And for me, coming home,

uh, and I'm not saying, you know, it's

always peace pre pe, you know, it's it's

beautiful all the time. Of course not. I

live in the real world just like

everybody else does. But, but for the

most part, home for me is an oasis.

>> And I and I think that's where you were

headed that you come home and you know,

maybe you didn't hit it all. You you you

didn't out of you didn't hit it out of

the ballpark. You didn't do this. You

didn't do that. But you're coming home

and what matters is your your people

around you love you unconditionally love

you.

>> You're set,

>> right? And

>> you're you're king.

>> Yeah. It's amazing. And I think that's a

really nice image despite the day,

however it went, maybe if it doesn't fit

what you thought it would be. But to

know that you're going to come back

home, you and your wife sitting on those

chairs, those thrones, that is still

going to be how your day ends. And it

sounds sappy and and and I and I but

it's the reason I say it like this is

because it's it's it's not it's not the

fairy tale land. It's it's it's it's

doable. It's doable

>> and it's a cognitive offload activity.

>> It's a huge cognitive offload activity.

Like and now five minutes into my my

throne the time with my wife I'm I'm

don't even think about the things. No, I

can I can appreciate that. And I

distinctly know that there's an inner

tension that occurs when you're trying

to grind through something and to

convince yourself, take that moment,

take that break, go message, go call the

wife, you there's a reluctance, but once

you do it, you can replenish yourself

and then come back stronger.

>> Absolutely.

>> Really amazing the the bringing it back

for high performers. So for high

performers across multiple fields and

that's the intent of of this podcast

this intent for high performers uh from

medicine to aerospace to defense what

simple habits help really build

cognitive resilience managing that

mental load before overload or that

replenishment and restoring clarity

under pressure. I know we've we've

talked about quite a few of them, but if

we were to summarize those habits.

>> Yeah, exactly. I think I think uh I'll

just summarize it because I think we hit

on most of them. Um I think

prioritization of your of of your life.

Uh what's what's first, what's second,

what's third, and that needs to be clear

because uh uh you have to make sure

you're prioritizing correctly. Um, I

think I'm I'm old enough to say uh and I

have the I have the right to say because

I've lived a certain amount of years

that that uh that the um the the

promotion, the financial stability is

not what what gets you and it sounds

sappy again but it's the truth. You

know, have you ever heard of a

destination disease? Have you ever heard

of that concept?

>> So I think many of us in our field high

performers and I would say I think it's

human nature

>> that we look at the destination

promotion. Sure.

>> A job, travel, I can't wait. I'm going

I'm going uh to wherever

>> and you miss every day because you have

the destination disease. You're you're

you're going for that. And then when you

get that, you're you're disappointed.

Very brief um very good example is u

have you have you watched Chariots of

Fire? Uh that movie recommended Academy

Award. It's basically about um a

Christian runner uh who is running in

the London marath 100 meter dash and and

his stance against he's not going to run

on Sunday. Regardless, that's not the

point. The point is the following is

that he had a very good friend who was a

better runner than him. And the night

before, this is a true story. The night

before the the 100 meter dash, they're

talking and this this friend of his

says, "You know, I'm so scared about

tomorrow." And the and the the Christian

friend says, "Why? I mean, you know, you

you you have this. I mean, you you're

going to win the race. You know that.

Goes, that's what I'm afraid of.

>> Because I've done all this.

>> Mhm.

>> I'm going to win. And then what?

>> And then what? Right.

>> Destination disease.

>> We've heard this with uh I know we've

come across this with Olympic athletes.

Once you get there and you win, then

what?

>> Look at even look at Hollywood.

>> Mhm. I mean you know you achieving

everything like you're famous money and

a bunch of very very very uh unhappy

people there and I think that's

destination disease. Yeah, I think it's

a it's a very prominent factor

especially with high performers because

you're working towards that goal, that

position.

>> You always have a goal, right? And

you're the I know I can I don't know you

well, but I know you're the same way.

>> And you and you live and if you and what

happens after that event and it's it's a

it's a tough

>> It's a downer. It's a downer if that's

your own death, right? But if your own

death is something that will stay,

>> yeah,

>> then then there's no downer. No, I think

it's a it's a it is a powerful

transition point. I mean, even as a

veteran, right, when when veterans

transition out, their goal was the

military and that defined who they were

for a number of years. So, when you get

out, what happens next, right? And

that's that's a significant challenge

and absolutely. So, we've covered so

much in in terms of dealing with uh

adaptive cognitive load that bandwidth.

So much to unpack here. And as we bring

this to a close, what I'd like to do is

pull on the science aspect and ask

yourself, so how do you see the science

of stress adaptation and cognitive

performance evolving over the next

decade?

Yeah, I I think um uh like we discussed

there these acute stresses bring about

um neurobiological

uh sort of built new circuits in our

brain and and uh they they cause us to

be more adaptive enhances enhancing our

memory and so on and so forth. However,

uh the the technology what we what I

could see coming down the pipes is

number one for for example wearable

sensors. So, um I mean this is very low

tech, but um I have a smart not this

one. I have a smartwatch and I and

during during these high stress events,

I look at my my my pulse and I see how

how that is and maybe things I can do.

Maybe I should have done more deb

breathing to bring it down a little bit.

But there's there there are a lot of

other sensors that can come down where

they monitor your heart rate. They they

monitor, you know, the way you maybe

perspiration. I'm not sure. But there's

definitely that's coming down and that

can using that data during high stress

maybe there are things you could do to

mitigate u how you deal with that uh

AIdriven uh sort of brain fitness

programs where where instead of

simulation medicine um you can you can

do um you can help AI give you scenarios

and and and and work through those and

and help you to build that new that

resiliency that that that will help and

and I think these are the things that

that I could see coming down the pipe.

Definitely AI is going to be a huge

cognitive offload. We have to be careful

how we use it for sure, but but I I

definitely see that being a big piece of

the puzzle.

>> Okay. All right. Really interesting to

see those trends come to fruition. Yeah.

Especially with the AI piece, but you're

we're building up some additional

awareness that can ideally help build

that cognitive bandwidth. Amazing. So,

Joe, thank you so much for taking the

time. Thank you.

>> This has been an absolute pleasure. I'm

going to be definitely knocking on your

door. There's so much more to unpack

here and we need to. So,

>> my pleasure. My pleasure. It was a It

was a true pleasure and it's a pleasure

meeting you and spending some time with

you.

>> Thanks again.