Healthcare Practitioners Performing Under Pressure

By Bonnie Hutchinson

“…At this point, I’ve got tunnel vision. Everything in the centre of my vision is completely clear and everything in the periphery is completely blurry. But I can see exactly what I’m doing. I recognize the situation… I’m talking to myself…

“I take a second. I take a breath, just one breath, in and out. I look around the room…

“With the scalpel in my hand, shaking profusely…”[1]

Mike Mallin, emergency physician, is describing a medical emergency in which the patient’s symptoms are not like anything the team has seen before. The patient’s oxygen and heart rates are plummeting; he is moments away from death. Mallin performs an emergency surgical procedure on the patient’s throat as other team members restore oxygen and heartbeat. The patient survives.

And then what? Mallin continues…

“My tunnel vision went away and yet, I was still, I was still just overcome with the stress of the situation. I could barely talk… I was just trembling so bad…

“Everybody else in the room was pumped and excited and went into high fives and chest pumps and doing all this other stuff. And like, I could barely talk. I remember looking around and looking at one of the residents and I looked at my hands and I was just, literally, I was just trembling so bad.

“And then I walked out of that room and immediately went to see the chronic abdominal pain patient who had been there an hour and a half waiting to see me, waiting to see if I could fix the problems that she’d been having for six months to a year, something like that. I apologized to her and told her that we’d been a little busy with a patient in another room and she was very nice about it.”


Most people on the planet do not experience the kind of stress described in that story. And if they did, most people would not immediately expect themselves to move into another situation that requires high cognitive ability. But healthcare practitioners in emergency medicine do that regularly. It’s considered “normal.”

Dr. Mike Mallin is an emergency physician and Ultrasound Director in Oregon. He told the story as part of a Dr. Scott Weingart EMCrit podcast,[2] not about ultrasound (for which Mallin is renowned), but about stress. Mallin said…

“I want to talk to you today about stress, about crisis, about how we as physicians respond to stress and crisis in these sorts of situations.

“And in reality, this is probably the thing that prevents us from performing at the top of our game, right? The medicine’s not that hard, right? We can all listen to a podcast, we can all memorize…

“Whether you can actually perform that procedure is all about how well you can compose yourself in that moment, how prepared you are for that adrenaline rush…”

And why does stress, that adrenaline rush, matter? “Because none of us can fight the fight, flight or freeze response,” Mallin says.

We are hard-wired for physiological responses to stress. They are beyond our conscious control. The sympathetic system kicks in to save our lives and our rational minds can’t stop that from happening.

Our automatic physiological responses to stress create at least two kinds of challenge to performing under pressure:

  • Cognitive stress – difficulty making decisions;
  • Psychological stress – difficulty performing tasks.


Mallin describes five states of stress response.

Condition white – a “normal” state. Heartrate is normal. We are relaxed.

Condition: yellow – heartrate is still normal but may increase slightly. We are aware that something needs our attention and we’re preparing to notice. There are no other physiological changes.

Condition red – heartrate is 115 to 145. We are definitely alert, with heightened senses. Our reaction time is shortened. We can still perform complex motor tasks but there is some loss of fine motor ability.

Condition grey – heart rate is 145 to 175. Cognition is slowing. Motor perception is slow. We experience tunnel vision. Complex motor skill decreases, gross motor ability is intact. We’re on auto pilot only.

Condition black – heart rate over 175. Loss of forebrain functions. We’re into fight, flight or irrational freezing. We experience loss of near-field vision, extreme vasoconstriction, loss of bowels.


Mallin says the optimum state for performing under pressure is somewhere about the middle of the red zone – heartrate between 115 and 145. In this zone we have peak cognition, peak reaction time, peak complex motor skills but some loss of fine motor skills.

During the medical emergency he’d described, in the moments just before he began to perform a surgical procedure, he knew he was too far into the red zone. “For whatever reason, I took a deep breath and it gave me enough relaxation to perform the task at hand.” It moved him in the direction of the yellow zone.


  1. The first thing, the hardest thing, the decision

Challenge: In a crisis, when we cannot stop the automatic physiological responses, our biggest psychological challenge is to make decisions.

Quoting from Laurence Gonzales’ book Deep Survival,[3] Mallin says Gonzales reports that 90% of people cannot think straight in a crisis. Of the 10% who can think straight, 5% still make the wrong decision.

The primary reason? All of us have a “mental map” of reality. We think we know how things are. But reality changes. Gonzales says that people who don’t survive are the ones who do not update their mental map to keep pace with changes in the external world. They are not “present” in the current reality. They are still reacting – and making decisions – from their out-of-date mental model.

In the medical emergency that Mallin described, the patient did not exhibit the usual signs that indicated what turned out to be the primary problem. It was a huge cognitive leap to “get” that the patient needed the emergency surgical procedure.

Solution: Mallin suggests three steps that medical teams can use to work around the fact that they may be working from an incorrect mental model, and therefore are at risk of making incorrect decisions. The three steps are:

  • have a simple algorithm,
  • re-evaluate the situation regularly, and
  • think out loud to the team.
  1. We’re all human

Challenge. In a fear response, the parts of the brain that are most activated are the thalamus, hypothalamus, amygdala, and hippocampus – all parts of the limbic brain. None of the frontal cortex is activated. Literally, we cannot think clearly or rationally.

Solution. We cannot change our biological responses. But two things we can influence are preparation and reaction.

  • Preparation. We know the best performance zone is between the yellow and red zone, where our cognition is alert and we have close-to-optimum motor function. So how can we prepare to be capable of being in that zone in times of high stress? Mallin says, “stress-inoculate yourself.” Put yourself in stressful situations and practice making cognitive decisions in those situations so you get more used to it.
  • Mallin says, “The best way to do that by far is through simulation.” When you’re in a simulation situation, you recognize that you’re stressed out. Maybe it’s not as bad as a live patient about to die in front of you, but you’re still stressed out. You are training yourself to manage those situations.
    As a sidebar, research shows that we remember things better when we’re stressed out. Data shows that you improve your 24-hour recall if the thing you learned happened while you had a cortisol release, as opposed to learning something when you’re in a relaxed state.
  • Mentally rehearse. Think about doing the procedure. Go through the steps in your mind. MRI data shows that when you imagine something, you’re actually activating the same areas of your brain just by going through it in your mind as opposed to actually performing the task. You can create motor memory to some degree just by thinking about doing it.
    Mallin says, “Even better is imagining the situation and then making it a scary situation.” And most important is that you imagine success. Never imagine failure.
  • The time for preparation has passed. Now you are actually in the situation.
  • The most important thing you can do is take that moment to breathe consciously. One practice is four seconds breathe in, four seconds breath out. Some people breathe in four seconds, hold four seconds, breathe out four seconds, hold four seconds. The more you can do the better, but just one breath will do.
  • Self-talk. In your mind, give yourself positive feedback. Say to yourself things like, “You can do this. You know how to do this.” As Mallin says, “It sounds corny but it works.”

Mallin’s final point. The more you can prepare the better.


It’s not the whole story by any means, but one resource that can help you prepare for times when you need to perform under pressure is Hone’s CUE recognition virtual simulation training. The down-loadable training modules help you enhance your diagnostic skills in the first few minutes of patient contact.

To find out more, visit where you can…

Learn more about Hone Cue Recognition virtual simulation training;

Be notified of updates and launch dates;

Apply to be a beta tester as new modules are developed for healthcare practitioners in high pressure environments.

The more you can prepare, the better.


Bonnie Hutchinson is a writer and lifelong learner with degrees in Education and Whole Systems Design as well as extensive training and experience in adult learning and teaching. As an organizational and evaluation consultant, she’s worked with many healthcare and healthcare practitioner organizations. She’s bestselling author of Transitions: Pathways to the Life and World Your Soul Desires.


[1] Quote from Dr. Mike Mallin, emergency physician and ultrasound specialist, during Dr. Scott Weingart EMCrit Podcast 164 (2015) – The Day I Didn’t Use Ultrasound,

[2] EMCrit Podcast 164 (2015), op. cit.

[3] Laurence Gonzales (2017), Deep Survival: Who lives, who dies, and why, W. W. Norton & Company, New York USA

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