Paramedics work in a an extremely unique clinical environment. We’re tasked with working in small ad-hoc teams, we’re required to make decisions that can have significant impacts on patient outcomes, and all of this often occurs in novel environments with many external stressors – making these decisions that much more difficult.

Join Will Johnston and Zach as they discuss how to calm the chaos and build highly competent teams to improve patient care. 


Will Johnston is a Primary Care Paramedic with the City of Ottawa, and a Medical Technician with the Canadian Forces Health Services Reserve. Will graduated from McMaster University with an Honours Bachelor of Arts in Psychology, Neuroscience, and Behaviour, and is currently undertaking a Masters of Science in Health Education at McMaster University.

Will has a keen interest in paramedic driven research, and collective competence and performance in ad-hoc clinic teams.

He can be followed on Twitter @seewillyj 

Show notes created by Will Johnston

Ad hoc teams: a group of individuals, who may or may not work together already, coming together for the purposes of this one task/goal.

Pressure Moments

Pressure moments occur throughout our lives and happen in everything from presentations, examinations, competitions, and of course while working. These are moments in our lives when regardless of the reality, we perceive that the results and consequences really matter. Pressure moments typically contain 3 key aspects

  1. The outcome is important to you
  2. The outcome is uncertain
  3. You feel that you are responsible for the outcome and that you are being judged for it. 

When we’re trying to perform well under pressure it tends to effect in three key areas: 

  1. Our physical arousal: the circulating stress hormones and subsequent physiological changes such as increased heart rate, blood pressure, and respiratory rate.
  2. Our thoughts: particularly how we perceive our current situation in terms of a threat or challenge appraisal; and
  3. Our behaviors: how we are acting in the moment and how we have acted in past similar moments. 

Each of these aspects has an impact on how we perform under pressure and also impacts each other in a strange feedback loop that if we’re not careful can cause us to spin out of control and cause our performance to suffer or even cause us to choke.

Threat-Challenge Assessment

One of the biggest indicators of how we will perform under pressure is how we appraise the situation. Specifically, how we perceive the balance between our resources and our demands.

When we perceive that our demands outweigh our resources we perceive the situation as a threat our arousal level continues to increase and our performance decreases.

If instead we perceive our resources exceeding our demands we perceive the situation as a challenge. We rise to the occasion and this arousal helps us improve our performance.

And the really neat thing is that it really is our perception.

When student’s taking the graduate entry exam were taught to reframe their anxieties as “helping them” and see the situation as a challenge they did better than their peers who weren’t given this advice. 


Grossman and Siddle

But our reactions to stress aren’t just cognitive there is also the physiological arousal. And one way to conceptualize it is  using the Grossman and Siddle model. This model, based on data from law enforcement and military personnel and divides performance into different coloured zones based on heart rate values.

Now although the physiological markers probably aren’t 100% correct, the general model seems to hold true. Initially as our arousal increases we have an increase in concentration and alertness which will plateau before we lose our fine motor skills and then our gross motor skills.

Grossman believes that we were able to temper these stress responses with training and that we can actually expand the areas where we are able to function under pressure.

But bottom line. It’s important to realize that there are different optimal levels of arousal for different activities. When you’re in combat you likely need a different level of arousal than when you’re trying to start a tricky IV on a sick patient.



We see these optimal models of anxiety related to performance as well in things like the Yerkes-Dodson law of arousal and performance or Mihaly Csikszentmihalyi’s model of a “flow” state.

The state where our level of challenge is just high enough to require all our attention without impairing our cognition. We are “in the zone”, time dilates, things seem to happen naturally and effortlessly.

And I’m sure that many of us have had experiences like this while working as well. In an ideal world every time that we had a sick patient or a complicated resuscitation we would be in this optimal arousal state.

Teams and Stress

Increases in pressure not only impact our individual performance but also impacts how our team performs as well. When we are stressed we tend to shift our focus and rely on heuristics.

At the same time the factors that we already discussed impacts how we perform our roles in teams. We can become task fixated we lose a sense of situation awareness for what else needs to be done. We tend to share less with our colleagues whether information that we’ve gained or things that we think are and need to be accomplished. 

Teams that are under high pressure tend to defer to the person who has the highest perceived “status” in a group. Even if that person is not the team leader, most responsible, or best person for the situation.

As team members aim to get more information and clarification we start to speak louder and over each other.

All of this makes it very difficult for the team to coordinate and work together towards a common goal.

Not only do we individually fall apart under pressure. But so do our teams.

In order to operate effectively our teams need to develop a “collective competence”. Collective competence is a group’s ability to perform together towards a common goal which could not have been accomplished by one individual due to its complexity.

High performing teams have the ability to collectively improvise, to adapt to disruptions and adversity. As a group they are resilient.

Across many disciplines from health care to business, the aviation industry, and the military there seems to be three characteristics of a high performing team.

First they have a team made up of individuals who are highly competent at their jobs.

Second the team has collective memory and knowledge which allows them to react to adversity.

Finally there are the appropriate organizational supports to allow the team and the system to be resilient.

High Individual Competence

High individual competence in high pressure situations is important for two reasons. First the individual is able to buffer some of the effects of stress and second they are able to act autonomously when required to perform tasks.

Although some people are naturally better at responding to stress than others, There are a number of learned techniques that people can use in the moment to buffer some of the stress responses.

Like anything people have to find what works best for them. But one model that provides a good basis as well as tends to put a smile on peoples face is the Beat the Stress Fool model by Lauria and colleagues.

Beat the Stress Fool

This model is an easy way to remember four evidenced based techniques to buffer stress in the moment. Plus, it always puts a smile on my face to think of Mr. T.


The ‘B’ for breathing, reminds us to focus on our breathing. By focusing on regulating our breathing we can actively lower our heart rate and decrease some of the arousal that we feel. This technique has been used by sports psychologists for years to help athletes lower their arousal levels before taking action such as a taking a free throw or during a break in play in big moments of football games.

We can use the same techniques to focus our arousal prior to performing a procedure or at a break or transition in our assessment and treatment such as the steps in our primary survey.

A commonly suggested method is tactical breathing. Also called box breathing or square breathing. In this technique you take a four second deep inhale, followed by a 4 second hold, a four second exhale, and then a four second hold. The exact timing here isn’t important but the focus on deep slow respiration is.

The slow deep respirations activate our parasympathetic nervous system and lower our heart rate. This works to lesson some of the impact of our physiological response to stress.


The ‘T’ or talk, is all about reframing the current situation from a threat to a challenge. By reframing our assessment of the situation we increase our performance.

Positive self-talk has been taught and used successfully across a number of disciplines from diving, gymnastics, exam writing, to professional darts.

There are different methods of self-talk from instructional: If you were ventilating a difficult patient for example. Thinking “good positioning, airway open, tight seal. 

To motivational: “I am intelligent, I trained for this, I can do this”.

There is a large body of research demonstrating the positive effects of positive self-talk on performance. Even suggestions as to what type of self-talk is most beneficial for what situations.

There are even general guidelines have been developed to help us create appropriate “self-talk phrases” (Mikes and Meyer 1991) 

  1. Phrases are short and specific
  2. Use the first person and present tense
  3. Phrases should be positive
  4. Say it with intention
  5. Be kind to yourself
  6. Repeat the phrases oftenWe can develop our own positive self-talk phrases while practicing to find ones that work best for us but,Regardless of the technique used when we are operating under stress,  positive self-talk can help us reframe our appraisal so that we are able to make better decisions faster.


Seeing, or visualization involves running through all the steps of a successful procedure or skill that you are going to perform. By visualizing the steps of a successful performance we are using the most high tech simulator we have in our heads to outline the process for when we actually need to perform.

When we mentally rehearsing an activity we are activating the same neuronal pathways that we activate during the skill itself. When we go to perform the skill under pressure we improve our confidence, concentration, motivation, and overall skill performance.

Although we typically think of this as a technique for technical skills or athletes, such as the basketball player before they have to take a free throw. Mental rehearsal has been shown to improve everything from police response to high threat tactical situations to specific surgical techniques.

There is even some evidence that mental practice can improve team performance. When anaesthesia and emergency medicine residents were randomized to 20 minutes of mental rehearsal and discussion with their partner before a simulated trauma scenario, they performed better than those who received 20 minutes of face-to-face instruction on ATLS trauma algorithms and non-technical skills. 

Visualization and mental rehearsal is a powerful tool we can use both immediately before and long before performing a skill to help us optimize our performance under higher pressure situations.



Finally, the “focus word” is meant to act as a cue which shifts our attention from general attention to selective attention for a specific task. In this context our selective attention acts as a spotlight which helps us perform this specific task.

Although we don’t always want our attention to be this specific it can help with critical interventions.

We can also use a focus word to re-center us when we notice that we have lost focus or are really feeling the effects of pressure.

The focus word is intended to be something personal. It can be motivational, instructional, or just a reminder to focus. Importantly the focus word should be incorporated into structured practice so that it maintains it’s effect.

Just like the high performance athletes we can use our focus word to help us get into the zone when we need it.