Editor’s Note: This is the third in a three part series.

Our Weaponry

We’re suitably attired in our physical armour, our psychological armour is fitted in the form of Ikigai and self-awareness – now what weaponry do we choose? It’s more than just ketamine and ondansetron!

Controlling the Body: Combat Tactical Breathing

It’s not just a tough sounding name, tactical breathing (or square breathing, or Yoga breathing….) is used by the military, SWAT teams, elite athletes, martial artists…. and now emergency physicians. Slowing our breath is one of the few mechanisms of physiological control we can use on ourselves during a stressful situation to override our sympathetic overdrive. It’s as simple as breathing in for four seconds, holding in for four seconds, breathing out for four seconds, and holding out for four seconds. Try it on yourself and you’ll find your heart rate slowly start to calm, helping you to avoid ‘condition black’: the point at around 175bpm where your cerebral blood flow is impaired enough for rational thought to become scarce (1).

A similar principal is used in taekwondo just prior to board breaking with the addition of the kiyup in lieu of the breath out (a loud shout involving tensing the abdominal muscles), delivered nanoseconds before the kick or punch makes contact. The kiyup allows for any last ounce of tension to leave the body, allowing the kick or punch to reach its maximum speed before making contact with the board. I do however find that shouting at patients tends to lead to trouble with Human Resources so maybe avoid this one at work….

Controlling the Mind: Automatic Thoughts and Cognitive Reframing

Similar to flicking a switch to turn on a light, we have particular intense moods that are associated with automatic thoughts (2). These are different for everyone, but we all experience certain moods that cause an immediate reaction in us. When a consultant says, “can you see me in my office please?”, to one person, this may immediately conjure sweat-inducing fear and the thought, “I’m in trouble! I know I’ve done something wrong!”; whereas for another person, the same situation conjures relatively little reaction other than intrigue. When we delve more deeply, the reaction of the first person may be intrinsically linked to flashbacks of overtly-critical feedback from their last consultant, and so cognitively restructuring this thought is required to override it.

In order to do this, Greenberger and Padesky in their book Mind Over Mood describe the following seven steps to identifying automatic thoughts and starting to restructure them (2):

  1. Identify the situation
  2. Identify the mood
  3. Identify the automatic thoughts: identify the one that makes you react the most (the ‘hot’ one)
  4. Identify any supporting evidence that the hot thought is true
  5. Identify any counteracting evidence that the hot thought is false
  6. Identify any alternative thought options
  7. Reassess your mood

For an example, a colleague of yours is attending a cardiac arrest and has started to feel overwhelmed, she’s visibly anxious (perhaps because of a previous arrest with a poor outcome). Her first automatic thought is “I can’t do this”, but the one that really makes her react is “I can’t do this, I’m not a good enough doctor”. Is there any supporting evidence to suggest that this ‘hot’ thought is true? Probably not. Is there any evidence to suggest it is false? Well she’s saved countless other arrest patients and she’s an experienced emergency physician, so yes there is plenty to say she can actually do this and is a good doctor. Then she identifies an alternative, “I can do this, I’m just anxious because of what happened last time. But we have an arrest algorithm, I can start with that”. On reassessing her mood, she may not be so anxious anymore.

When it comes to sparring in taekwondo, we face a similar predicament. When faced with a much larger opponent, it can immediately provoke fear associated with the automatic thought of, “I am going to get hurt because she is better than me.”  A quick appraisal of the evidence often finds that while yes, the opponent may be larger, she may also be slower because of her size, and so basing the comparison on size rather than agility is redundant. As someone who is 5”3’ at best, the alternative thought of “she may be bigger but I am faster” is certainly more effective at alleviating the anxiety of the situation.

Our Army

From our colleagues of all disciplines on the floor with us, to our supporting family and friends at home, to our specialty college itself, it takes an army of people to run an emergency department. We simply cannot do this alone, so who do you choose to join you in battle?

Our Failure Friend

While you can’t necessarily choose your family or colleagues, you can choose your friends. Cherish the close ones, make new ones at work when you can, and don’t neglect the non-medical ones. Fill your life with people instead of stuff (because a CMAC is useless without the person operating it!).

Intensivist Sara Gray (@EmICUcanada) noted at this year’s SMACC conference the importance of having a failure friend: the person you can turn to when you’ve made a mistake, someone who you can confidently debrief with. We work in a culture where we place the expectation on ourselves to be perfect despite the glaring human reality of imperfection (and as Voltaire once said, “perfect is the enemy of good”). Having a failure friend means allocating a person who gives us permission to grow and learn through mistakes – and therefore become better clinicians.

Our Mentor

Behind every good army, much like every successful team or sportsperson, is the coach or the mentor. Mentoring has been shown to improve wellbeing, professional practice and development as three overlapping domains contributing to two main skills – managing change and solving problems (highly relevant to a career in emergency medicine) (3). In addition, where improvements in personal wellbeing and professional practice overlap, a mentee has been shown to experience more confidence and job satisfaction – and ultimately an increase in performance (3). These areas amalgamate to not only strengthen our armour as doctors, but also positively influence the care we can give to our patients, and that can only be a good thing.

The Take-Home Points

Everybody is fighting their own battle, even if you don’t realise it. Whether that be the day-to-day stresses of our emergency departments, or getting both figuratively and literally kicked in the guts at taekwondo, we can all do things to add to our arsenal and help shine our physical and psychological armour to be battle-ready.

In a nutshell:

  • Don’t just wear the scrubs – embody them.
  • Don’t dismiss your lucky charms!
  • Find your Ikigai.
  • Ask yourself, are you okay?
  • Tactical breathe like a boss.
  • When you’re feeling anxious, identify the situation and your mood, find your automatic thoughts, challenge them, reframe them, then check back in with your mood.
  • Find a failure friend!
  • Never underestimate the power of mentorship.


  1. Grossman D, Christensen LW. On combat: The psychology and physiology of deadly conflict in war and in peace: PPCT Research Publications Belleville, IL; 2007.
  2. Greenberger D, Padesky CA, Beck AT. Mind Over Mood, Second Edition: Change How You Feel by Changing the Way You Think: Guilford Publications; 2015.
  3. Steven A, Oxley J, Fleming W. Mentoring for NHS doctors: perceived benefits across the personal–professional interface. Journal of the Royal Society of Medicine. 2008;101(11):552-7.