Episode 37 – The Emergency Mind – Dr. Dan Dworkis

Jon Becker: My guest today is Dr. Dan Dworkis.

Dan is a board certified emergency physician, an assistant professor of emergency medicine at the Keck School of Medicine at USC, the founder of the Emergency Mind Project, and the chief medical officer at the Mission Critical Team Institute.

Dan performed his emergency medicine residency with Harvard Medical School at the Harvard affiliated Emergency Medicine residency at Massachusetts General Hospital Brigham Health, and holds an MD-PhD in molecular medicine from the Boston University School of Medicine.

Dan is the author of the Emergency Mind wiring your brain for performance under Pressure. He's also the host of the Emergency Mind podcast. I'm excited to have Dan on The Debrief because he not only has a unique blend of scientist and practitioner, but he is someone who has spent a great deal of time and thought deeply about how our minds work in critical incidents. Additionally, through his work with mission critical Teams Institute, he has looked at how those principles apply to tactical operators and first responders.

I hope you enjoy my chat with Dr. Dan Dworkis!

My name is Jon Becker.

For the past four decades, I've dedicated my life to protecting tactical operators. During this time, I've worked with many of the world's top law enforcement and military units. As a result, I've had the privilege of working with the amazing leaders who take teams into the world's most dangerous situations.

The goal of this podcast is to share their stories in hopes of making us all better leaders, better thinkers, and better people.

Welcome to The Debrief!

Dan, thanks so much for being here today, man! I'm really looking forward to this conversation!

Dr. Dan Dworkis: Absolutely, Jon. Thanks for having me!

Jon Becker: So why don't we – let's start with kind of your bio and background, because I think it's relevant in this case to where you end up with the book.

Dr. Dan Dworkis: Yeah. So I am an emergency doctor, and these days I'm out in Los Angeles, but going back a time a little bit, sort of how I got on this path. Right? So I actually started more as a scientist, figuring I would do mostly science and stay away from anything, people or anything related, which I was clearly and thankfully wrong about.

But so I ended up doing an MD and a PhD in molecular genetics, which is a weird combo. Thought for a while I was going to be building medical devices as kind of a career, and then somewhere along the line, absolutely, absolutely fell in love with the emergency department. I think most of us in medicine have some moment where you realize you are just a certain shape, you're just cut out for a certain thing, and that's just like you're shaped in a way, and the universe is shaped in a way, and that's just how it fits together.

I have this very strong memory of being pretty junior medical student, and it's like three in the morning and I'm on a trauma rotation and I'm just, I just, I just can't stop thinking about the ER, man. I just want to go down there. I want to see it. And I conned my way out of whatever it was I was supposed to be doing and went down to the ER and just kept doing that and kept doing that over and over again. Just absolutely fell in love with those folks who were down there.

You know, these are the people, you know, on the civilian side and in the medical side. These are the folks that are there when things, you know, go bump in the night. They're the first, they're the first line. They're what catches whatever comes in. And I just loved these folks and the energy and the chaos that they brought to it. Decided that be my path, kept training in it, and then over the last, geez, I don't know, seven or so years I've had a career out here in Los Angeles, mostly attached to what's now called LA General Hospital, which is one of the busiest ers in the country, doing a combination of medical care and teaching junior your doctors and thinking more and more about this concept of how do we apply knowledge under pressure. Right. How do we really function at the cutting edge of emergencies?

Jon Becker: So, La General Hospital, previously county USC?

Dr. Dan Dworkis: Correct. The artist formerly known as LA USC.

Jon Becker: Yeah, yeah. Which if you don't know LA, if you get shot in LA, you're probably going to now, LA General Hospital.

Dr. Dan Dworkis: Pretty high chance where who's catching you?

Jon Becker: Yeah. If you're, and if you're lucky, you're going to.

Dr. Dan Dworkis: There are some great hospitals out here, but we're the, you know, we're the flagship of trauma. Absolutely.

Jon Becker: Yeah. Yeah. If nothing else, because of the volume and, and intensity of your job out there.

Dr. Dan Dworkis: I think also, you know, they're there like a lot of teams, there are self reinforcing cultures and cycles. Right? If you're a team that, that is in the middle of it, that is prides themselves on their ability to handle chaos and resuscitation and, you know, high complexity medical and traumatic care, then you tend to attract people that want to perform in those environments, that want to be part of that. And so it's a pretty good virtuous cycle from that perspective.

Jon Becker: Yeah, I think it's kind of the doctor equivalent of working at a ghetto station on graveyards on Fridays and Saturday nights. Right. The guy that seeks out the emergency department at La General is the guy that would work that station. You're looking for the edge. You're looking for the difficult case and the dangerous and the high risk and the high volume.

Dr. Dan Dworkis: Yeah, we're a little weird. Yeah, I'll take that.

Jon Becker: Yeah. That's also what makes for really good ER doctors. So when did you first get interested in kind of human performance questions? What was the triggering event for you?

Dr. Dan Dworkis: Yeah, I mean, so I'm really lucky that I have a background in training martial arts, right? I was really lucky. My parents put me into that when I was a young age. It was a karate school. Right? There wasn't. We didn't really have like jiu jitsu and Muay Thai and sort of mixed martial arts back then the way we do now. But it was a karate school and a great teacher. And so from a pretty early age, I had this concept that there's a difference between knowing something in theory and being able to do it in reality.

That was part of my growing up, because if anybody's ever been done any martial arts training, it's very easy to say, here's how you do a particular move, and then it's a lot harder to do that when somebody's punching you in the face over and over again. So there's this gap that's just blindingly obvious. And when you're on the wrong side of the gap, you literally get hit in the face, which is a very strong teacher.

So I had some of that mindset coming into emergency medicine, but a lot of times medicine, we don't necessarily train with that in mind. Right? Like the standard sort of medical system trains you a lot about the what and a lot less about the how. So, you know, here's your knowledge. Here's your knowledge. Here's your knowledge. And then you're sort of left on your own in a lot of ways to figure out how to apply that knowledge specifically to these high stress, you know, high complexity cases. There are some pretty vivid memories for me that, I mean, ultimately, Jon, the answer is that I failed. Right? I failed.

And then I got interested in figuring out why, right? Because you go into a room like this and there's somebody and they're suffering and maybe they're in cardiac arrest or they are, you know, choking on something or their oxygen levels are super low and you have to act on it.

And the first couple times I did that, I got stuck. I'm not going to say I went, like, totally into vapor lock, but it was pretty close, right? I didn't know what to do. I had all this theory, all this stuff in my head, and I couldn't figure out how to get it out of my head and into my hands and into the patient. And that sucked. That sucked wildly. You go home from one of those moments and you're like, holy s***, this human being suffered because I couldn't perform at the level that I wanted to perform at, even though I know, theoretically, how to run that case. Right?

I understand what the theory, I understand the medicine. I understand how to do it. I couldn't figure out how to get it from my head to my hands. Why is that? And that sort of set off this flag for me that was like, oh, well, I remember feeling this when I was really young doing martial arts, too. So there's got to be some parallels here.

Probably, there's stuff that other people had figured out. And that sort of impetus with the fire underneath me of not wanting other people to suffer because I couldn't play at the level I wanted to play at, is really what started this whole idea of, how do we apply knowledge under pressure? It certainly wasn't that well thought out of a question when I started. It was more of like, Dan, why do you suck so much? Right? Trying to suck less.

But over time, thankfully, that got sharpened and shaped a little bit into this concept of, like, how do I, and really, how do any of us apply knowledge under pressure? How do you build teams that are able to succeed in times of crisis, stress and emergency, which is really the. Pretty much the central organizing question for my life these days.

Jon Becker: Yeah, one of the things that I'm constantly looking for on the debrief are people that are kind of immediately tangential, you know, immediately adjacent to tactical operations, because there are a lot of parallels between a sniper having to take a difficult shot on a hostage or a team having to make a high risk entry or a tactical leader having to make a decision or a medic having to deal with a multi.

All of those things, the performance issues that underlie them are the same. They are the same. The underlying. I just interviewed Rich Devinny, and the underlying attributes of what makes you a good er doc is in many cases, very similar to what makes a good DEVGRU seal. It's just applied in a different direction.

And so when I first listened to some of your work and read your book, it was just really clear that there's just a lot of overlap here. And what I like about it is that you clearly have given a lot of thought to it, and it's not, I don't know, listening to interviews with you, reading the book, it's not an intellectual exercise for you. It's a very emotional. You can feel that it resonates for you in a way that I think makes it probably a little more profound.

Dr. Dan Dworkis: You know, I've had the. The fortune and the. No, I'll go ahead and I'll call it an honor. The honor to work with a lot of different groups over the last many years, some of which are our warfighters and allied warfighters, and some of which are firefighters and folks in aerospace and all sorts of stuff like this. And, you know, what you're saying is really true. This is nothing like we need to bring intellectualness and theory to this because we got to figure it out, because it's a problem that matters.

But when we don't figure it out the right way, this is real life. This is blood. This is somebody not coming home or us not being able to bring somebody back. This is real. Right? And you're totally right about that. This isn't a theoretical exercise you're running on paper because you want to increase the, you know, percent you take home from something or I other on the financial side. Like, you know, you're doing this because this is real life.

Jon Becker: Yeah. It's not just quant math. Right? And I think one of the things that's very difficult, spending my entire adult life in this industry, it's very difficult to articulate how real everything is. Like, how every decision that people make has a life in the balance. And it does, I think, is one of the things, actually, that isolate in a lot of cases, or special operations warriors, our tactical operators, our first responders, is this understanding that they're doing something that is so critical, much like an ER doc, you have somebody's life in your hands every night you work, and a mistake has a really high cost, and that drives a certain amount of pressure, internal pressure, external pressure, and a certain emotional footprint that I think is difficult to articulate.

Dr. Dan Dworkis: Yeah, I think it's interesting what you said a few seconds ago about how it's the same structures in the person applied in a different direction. I think there's actually two complementary pieces to that. One is the person. What do you think and feel, and how does your brain work, and how do humans brains work under pressure? And we can talk about that a little bit, too, but the other is the fact that the problem sets are actually somewhat parallel to each other. I think this is what you're getting at right now.

The challenge that you're facing, to me has this very specific shape when you talk about an emergency, and it doesn't really matter what the emergency is. In the book, we talked about three factors, and I've actually added two to my list since then because I think it's worth talking about. What is an emergency, and why do we care if you're not even doing medicine about this?

To me, the things are impact, pressure and uncertainty, and those are the core, like you said, high stakes life, death or catastrophic loss. In terms of impact, this isn't, do you get the coffee order right? This is real bad things happening. Pressure is this mismatch between resources and demand on those resources. Often that's time for most of us.

There's just not that much time to make these decisions or to make these plans for it. You know, my friend and mentor and sort of co conspirator, Preston Klein, talks a lot, about 500 seconds or less being the timeframe that we all work a lot in. That number comes from sort of back ending into if you stop somebody from breathing about how much air do they have left in them before bad things start to happen.

And that's like an optimistic number, right? That's like you've prepared to stop breathing and you're stopping breathing and like, you know, you're getting ready for it. That's not like a, your lung is damaged already or something else is going wrong with you. So it's a pretty optimistic number.

But anyway, there's a pressure mismatch between what you need to do and what you have available to do it. And then there's huge amount of uncertainty. You don't know the problem, you don't know the solution, you don't know both of it. There's so much uncertainty that we operate in, and I would typically add to that also this idea of complexity. We work in really complex systems, human interactions, human environment interactions. These aren't simple, straightforward decisions. There's hidden consequences and higher level approaches to it.

And the last thing I'd throw on that list is liminality. And I think that's what makes part of our work so interesting and weird. Right? You cross a line, you can't undo it, right? Liminality says you've crossed some boundary and you're now in this alternate world that's different than the world you left, and the only way out is through.

So the easiest way to think about this is you've launched a plane, the plane is in the air. The plane has to land eventually, right. You have to come out of that. The only way out is through. You either land the plane or you crash the plane. For us, it's the same way comes out a lot when you're putting an airway in, right?

The person is not breathing. They're in this liminal space that the only way out is through. You have to secure that airway somehow or they die and you mash all those things together and you get this real, really unique environment. That is what an emergency is.

And so I think it's worth talking about the operator, to use that term, whoever's actually in that space. Also the situation itself. And there's so many parallels in there between all of these different worlds that we're walking into. I realize it's a huge tangent, maybe not what we're talking about, but that seemed worth putting in there.

Jon Becker: No, it's actually a very interesting tangent. I'd like to push on it a little harder.

Dr. Dan Dworkis: Yeah.

Jon Becker: So go back through that. Go back through the factors for me one more time. What creates an emergency?

Dr. Dan Dworkis: Absolutely. And I don't know if this is, I don't know if this is what creates an emergency or this is just when I look at emergencies, they have these things and you can sort of backend into it with it. So impact, pressure, uncertainty, complexity and liminality.

Jon Becker: Yeah, that's really interesting way to characterize it. And liminality is actually that. You taught me my new word for the day. I try to learn a new word every day today. Not solid liminality. No, I think, it's a really interesting point because like you said, once, once the plane leaves the ground, the plane has to either land or crash. There is no, you cannot, you can, you can delay that decision till it runs out of gas, but then it's not a decision anymore.

Dr. Dan Dworkis: Sure.

Jon Becker: And so, so many of these decisions that you're having to make in, in the circumstances that you're in, the circumstances that our clients are in. One of my favorite quotes is there was a rush song and one of the lines in the rush song from the great prophet Neil Peart. Even if you choose not to decide, you still have made a choice. And to some degree, liminality is exactly that. Once it begins moving, you've got to either land it or crash it.

Dr. Dan Dworkis: Yeah. I think that when you look at a lot of the different types of teams that operate in these environments, emergency or otherwise, one of the things that does sort of draw us together that we have in common is that some teams operate never in emergencies. Never. They're never emergency teams. They just do standard stuff. Sometimes they'll hit one or two of these factors, but they'll never operate in a world where all of these things are going at once.

But for those of us that are what I call, what I guess I'd call like a crisis native team. Right. Where we believe that we function in crisis and emergency. That's part of why we exist. We go back and forth between these two worlds all the time. Right?

99% of our day, even in the ER, might not actually be an emergency. But at any point in time, all of a sudden these five lights turn on and you might be right there, right in it, right in the middle of it with no warning. And so you don't really. You don't only have to function in that space, you also have to function back and forth between the normal world and that world.

Jon Becker: Yeah. And be comfortable with the fact that you don't get to decide when you enter that world.

Dr. Dan Dworkis: Exactly. Yeah. Lucky you got a little warning.

Jon Becker: Yeah, yeah, yeah. But realistically, it's like, and I've heard you describe it or you describe it. Heard you describe it and I've heard other ER docs describe it in the same way that I've heard kind of tactical operators describe it is, yeah, you're going to, the flag goes up, you know, you have two minutes. Take that two minutes, use it wisely, center yourself, get your bearings, start the process, try to accelerate your brain into the problem before the problem gets there. But realistically, it's – You've got two minutes. You know, you don't have five days to plan.

Dr. Dan Dworkis: Yeah, I mean, I think, you know, you sort of think about some of the problem sets that we work right. So we'll often get, you know, a radio call and, hey, there's a, you know, gunshot wound to the chest, victim coming in, you know, ETA three minutes, bad vitals. And it's a kidde. And you're like, okay, that's all the information you get. What are you spinning up? What resources are you putting into play? Who else is sick around you in the pod that you have to shift resources from? Given the doctor nurse ratios that you have, how do you devote the right resources to this? Oh, and by the way, there might be actually three people instead of one person. Like, okay, what are you going to prepare for?

And that at least gives you a minute to sort of, like you said, to accelerate your brain into the problem. But also, it's not just you. It's your whole team. Right. How do you get your whole team on point, fighting the same battle, doing the same set of things? The opposite from that is the second problem set that we often face is what you would call, like, a zero notice event. Right?

The code blue goes off somewhere in the hospital, meaning somebody's heart has stopped and somebody's hit the button. And one of us leaves the ER with a bag of gear, sprints upstairs, and goes to take care of that person, and they lead what's called a swarm team. They'll basically assemble whatever team is around and available and have them work the problem set together, which is really kind of a different and separate problem set, because in one case, you have your team who you know and you train with and you operate with another team.

You're leaving your environment and assembling whoever's there to do the best that you can with it. I mean, almost all of us have stories about responding on planes or, you know, I ran a cardiac arrest in a hair salon once. I was just walking by. Like, there's just, like, things that happen, and you're sort of like. You have these zero notice events that you just snap into that. Into that emergency space.

Jon Becker: Yeah. And it does. When you look at it from that perspective, it is kind of two different. It's the same skillset, but it's two different variants of the skillset, because one is known resources, known capability, and unknown problem. The other is unknown problem and unknown resources and capability.

Dr. Dan Dworkis: Spicy.

Jon Becker: Yeah, to say the least. So let's dig into the book a little bit. So the book talks about five major areas, and I'd kind of like to go in and just push on each of them a little bit and just. Just kind of massage them out. So just to give a roadmap of where we're going, the five are applying knowledge under pressure, handling uncertainty and imperfection, supporting critical decisions, building from core values, and balancing competing forces. Why don't we start with applying knowledge under pressure?

Dr. Dan Dworkis: I think it's worth taking a second first and being like, why did I write this? And what's the point of this? Right? Like, why does this book exist? And part of the answer is, it exists because it's what I wish I had when I was coming up. Right? You know, you go through these cases and you go through those moments, like I talked about, where you don't perform at the level you want to perform at, and you go home and you somehow have to live with that, right?

And, you know, if you're lucky, you're going home and you have mix of people around you, some of whom understand what you're going through and some of whom live outside of that world. And you do normal human things. You know, you do the laundry and you eat dinner, but in your mind, you're like this human being suffered because I wasn't there the right way. And it's a bridge that's so hard to cross, so hard to communicate about that.

And I, you know, I'll be honest, I struggled with it, right? I really struggled with it. I sat on stuff I should have processed and didn't, and it built up and built up. And, you know, I would come home and beat myself up about these things. And there wasn't a lot of logic in terms of how to train to get better at it. And I wrote this book hopefully to at least provide a starting point, a set of questions, a set of ideas to folks who are going through some parallel journey like that on some path. It certainly is not, you know, an exhaustive and perfect map of how to do things by any stretch of the imagination. It's much more of a starting point in conversations, in a seed.

And so usually when I talk about this, the first thing I say is that although it looks like maybe I'm talking to somebody about this and I'm the one giving the knowledge, the reality is we're both on the same side of this problem set. Right? And so if you're listening to this, you're on the same side of this problem set with me. And we're both trying to figure out how to apply knowledge under pressure.

So my hope is that whatever I say in this, if you have better ideas, that you reach out and tell me, because I need that and my patients need that. We all need me and you and everybody to be sharper about it as we do it. So there's some cool stuff in this book. Like, you know, I'm a little biased, but I like it. There's some cool stuff in there. But to me, I think the most important fact piece of it is that it is incomplete. It is a starting point, not an ending point, about all this.

Jon Becker: Yeah. And it reads that way. I mean, it's interesting because it is certainly, I mean, there's a lot. There's a lot to the book and a lot of depth and understanding in the things that you have researched and you have figured out. But there is a theme throughout of trying to figure it out. Like it's, you know, there's a lot of talk in the tactical community. The difference between post traumatic stress and post traumatic growth.

Dr. Dan Dworkis: Yeah.

Jon Becker: The book actually feels like post traumatic growth to me. It feels like you being unhappy with your performance, struggling with it, and then finally, you know, like, learning your way out of that feeling. And how do I. How do I get better every day? And then how do I share that information?

Dr. Dan Dworkis: Yeah, John, that's just about the nicest thing anybody's ever said about the book. Thank you. It feels like post traumatic growth. I'm gonna write that down. That's great.

Jon Becker: It does. No, I mean, it's – The thing is, like, sometimes you read books and it's like, here's all the s*** I screwed up, and this is what I should have done, and it doesn't have that. We can get better, and I am getting better. And I think one of the things I really liked about the book is, and all of the interviews that I've heard with you is this kind of notion of, like, I'm not happy with my performance today, and my performance is going to get better.

One of the podcasts I listened to, an interview with you, you talked about when a patient dies, putting your hand on a patient. And I would love you to tell that story, because I think it is, from my perspective, it reveals a lot about you and your thought process.

Dr. Dan Dworkis: Death and suffering are realities of the world that you work in as an ER doctor. Right? We're very aware of the critical difference between performance and outcome in a lot of ways. Right? Outcome is what happens. Performance is how well you do your job, how well you live up to your capability and abilities. They are, in our world, not perfectly correlated. Right? You can perform at your absolute best, and it's just that person's time and they still die. Or you can fumble every which way and get lucky and the person lives. Right? And either way, you still have to learn from what happens, and you still have to get better at it.

So one of the thresholds and sort of rituals that you come to figure out as you're training is, what do you do when somebody dies? Because it happens to all of us. Thankfully, it's not all the time. Thankfully, we save way more people than we lose. But it does happen. So early in training, somebody gave me this, introduced me to this rubric that I now use and that I've taught generations of ER doctors with. And it's to take a moment, this person in front of you has just died. And there's a realness to that, right? There were ten people in the room before and now there's nine. And that's real.

And there's so many other things going on and there's such a draw to sort of move to the next thing and to just keep running because there's other patients that need you and there's other things that are happening. And what we do, what I do is to slow myself and my team down and take a moment and just take a moment and think about this human being that used to be there.

And you draw it out, you think about them and you put your hand on them. Usually it's on their foot, because that just happens to be where we run most of the cases from, for various reasons. Put your hand on them and you say, thank you for teaching me, sir, I'm sorry. All I could do for you today is to learn. I'm sorry. All I can do for you today is to learn.

Jon Becker: That is such a profound statement. Is such a profound statement on both sides of the. I mean, it is almost by definition setting your brain for post traumatic growth. Right? I'm sorry that the trauma that you went through and that I went through has left you here and me only able to learn. But I heard that story and it hits me exactly the same way that it did the first time he hit. It is just such a profound statement.

And I think it's worth people taking a moment to think about, because so often the guys that we work with and the guys that are in our audience are in that same circumstance. They're not able to rescue a hostage, they're not able to save somebody in time. They're not able to stop somebody from being in a fatal car crash or save them after a traumatic event or whatever. And what I liked about that the first time I heard it and what I like about it now is it is that moment.

Two things that you're doing. One, you're preparing your brain to move past it in a constructive way. But two, you are also conditioning yourself that you need to learn from every single one of these events.

Dr. Dan Dworkis: Yeah. It doesn't stop there. Right. You don't get to tell that person, I'm sorry. All I could do for you is learn and then not learn to. Right. That is, to me, unforgivable in some sense. Right. I can't, as a doctor, I can't promise I'm going to save everybody. Unfortunately, I can't even promise I'm going to relieve all their suffering. Medicine is pretty d*** amazing, but we can't do everything. And I really wrestled with that.

So if I can't promise I'm going to save them, and I can't promise I'm going to make them better. What can I promise them? What makes this worth going every day and throwing yourself into this pit over and over again? And to me, the answer is, I can promise them that I will learn, that I will do my best, and I will learn, and I will never waste their suffering. I will never waste their suffering.

Jon Becker: Yeah. One of my mentors, Mike Hillman, who was one of the original guys at LAPD D-Platoon, says, never waste a crisis. Right? Like, never. Never waste a tragedy. Never waste a crisis. You know, something horrible happened to someone, to you, to you, to everyone. Don't allow that to just be thrown away. Use it to find strength, improvement, knowledge. And it's interesting because that is the context of the book. The stories throughout the book are stories of you failing. Right? Not necessarily failing and losing a patient, but failing to the standard that you're holding yourself to and then coming back and going, all right, why did that happen?

Dr. Dan Dworkis: Yeah. And I think that's, you know, it's hard to talk about still, right? But, like, most of us carry around these images in our head of people that we've lost or that we couldn't do the right thing for, whether it's people we work with or our patients.

Yeah, I think you nailed it. I wrote this for them because it's a way to honor them, and it doesn't fix it, and it doesn't make it whole, but it doesn't waste their suffering because it's too d*** precious of a fuel. Right. It costs so much to put together, and you have to use it. You have to get better. You have to get your team better on it.

Jon Becker: I think it's true in all. First response, whether it's tactical situation or medical situation, I think that there are a. You know, there is an abundance of suffering all the way around. Right? The people in the event, the people responding to the event. You know, one thing that I was on a podcast recently talking about shootings, and one of the things I said is, you have to understand that nobody leaves the same that they got there, right? The cop that shoots somebody who righteously needs to be shot. Right? Like, assume best case scenario, the guy really needs to be shot, and it is a perfectly righteous shooting. His family is still affected. Everyone around him is. It creates a ripple in their world, in every single person's world, that resonates.

Dr. Dan Dworkis: Yeah. So one of the ways that we talk about this a lot that's useful. I think a useful idea behind this is expensive learning and cheap learning, right? So what you described, what we're talking about when we're really dropped into this, talking about the death and the suffering, that is expensive learning. That costs a lot, right? That's learning at the expense of lives, learning at the expense of suffering, of challenge and hardship.

And one of our jobs collectively as tribes that do this kind of work is to derive from that cheap learning for the people around us. Can we tell the story about it in a way that teaches the next generation of people so they don't have to make that same mistake? Can we talk about what happened in a way that allows us to grow and build from it so it amplifies the good effects of it? And can we produce cheaper learning all around for it?

To me, that's a really cool way to think about it because it provides an impetus. That part of your job is making derivatives of what happened, which is not super obvious all the time. Some of the time you're like, oh, the teachers do the teaching, the operators do the operating. But actually, it's all of our jobs. If you're in this space to train and build and make everybody around you better, if you really believe that your job is to never waste suffering, then it's on all of us to be instructors at the same time that we're operators.

Jon Becker: That is a brilliant way to put that. I always use the analogy of rattlesnakes. The first guy that found a rattlesnake got bit by it. And if he didn't tell anybody, the second guy, the third guy, everybody continued to get bit by it. For the guy that gets bit by the rattlesnake, that is an expensive lesson, right? It might cost him his hand. It might kill him, right? That's an expensive lesson. To the person he tells the story to. It's free, right? Like, unless the story is being told to his wife, like, the next guy he meets is like, hey, man, this is what a snake looks like. Don't pick it up. It bites you.

There's zero cost in that learning for that guy. And part of the reason that we created the debrief, part of the reason that we've done a lecture series, is so much of this knowledge is just paradigm based decision making. It's just knowing if this happens. If you find a long cylindrical object with a rattle on the tail, don't pick it up. I've never had a construct with, to teach it the way you just did, though it's expensive learning and cheap learning. And I think that the book is a lot of expensive learning for you. That is almost free learning from.

Dr. Dan Dworkis: Exactly. And that's the point. That's exactly what I wanted to do with it. Right. Was to capture some of that and hammer it into something useful and pass it on to folks as a starting point. Something that gets you forward ahead of where I am from it. And I think this gets to one of the other key points we talked about, not wasting suffering.

And I think that part of the way you do that and the way that you transmit this learning gets back to this like incredible maori idea, which I'm gonna butcher the pronunciation of whakapapa. Right? The idea that you are the summation of your ancestors dreams and hopes. And today the sun is shining on you and it's your job to move the chains forward. And it won't always be your turn. It was their turn once, and it'll be somebody else's turn after you. But while it's your turn, what the f*** are you gonna do with that, right? How are you gonna live your life?

Jon Becker: When it's your f****** ball forward?

Dr. Dan Dworkis: Yeah, exactly. Yeah. And I think that's like part of the joy of this is, you know, we've all chosen to be in this weird space, this extraordinary world that's different than the average set of human experiences. We're doing things expensively, we're suffering, we're learning from it.

And we have the ability, as we're in the moment of that sun and moving the chains forward, to leave the earth a better place after us for the next group of people that are, you know, the next John and the next Dan and the next, you know, Jody and everybody else who's out there behind us, who's coming up, who's gonna be better than you and I were at our jobs, hopefully because of what we do, because they get cheaper learning, because they don't also have to get bit by the d*** rattlesnake if we do our jobs. Right.

Jon Becker: I. Yeah. And one of the things I love about kind of the modern information environment, right, whether it's podcasting or publishing, you know, web publishing is the cost of information. Like, like Dan, Dan's book doesn't get published 40 years ago because he can't find a publisher that's willing to put enough money because it's not going to be a bestseller. Right, totally.

And Dan and John don't have this conversation because they can't get a network that's going to spend money for the 5000 or whatever people that are really going to care about this in the world, I think.

Dr. Dan Dworkis: And we swear too much and we're too ugly for television. I get it. Yeah.

Jon Becker: I mean, I don't want to lump you in. You could have just stopped at swear too much. That's fine, Dan. We'll just move on, I think. Yeah. It's interesting, because I said in the intro that one of the things I like about the work you're doing is it's very clear you thought about this at a very deep level. Right? This is not just like, oh, hey, here's a way to not make a decision, or here's how to not screw this up. You're thinking about this not only from a future generation and cheap learning, expensive learning, but also the way you dissect the problem, I think, is very interesting.

The way you split the book up is interesting in that it's not only like making decisions and, you know, you spend a three of your sections are really about decision making. Right. But it's also what is affecting, what are the external forces on the decision, and then what informs decision at a core level, what underlies it.

So why don't we – Let's start with the decision making thing and just push on it a bit. Totally. Talk to me. Let's start with decision making. Applying knowledge under pressure. Because one of the things that you articulated beautifully is you spent all this time in medical school. You have the skills, you know exactly what to do, but now you have a patient in front of you who's dying.

You know, he has X amount of time left to live, and you have to bring that knowledge to bear and execute in the time he has. So, like, he walks in the door with a timer on, and now you have to harvest your brain and skills within that timeframe. Walk me through what goes into making a decision under pressure.

Dr. Dan Dworkis: Yeah, there's so much in there, and I think it's worth, for a moment focusing on the moment of actually making a decision. But hopefully, then we'll zoom back out to the whole context, because there's stuff that happens before, after, and the next day that really influence your ability to make that decision.

Jon Becker: Let's just do it in that order. Then take me from the beginning. Walk me through it.

Dr. Dan Dworkis: When I first did this and first started really digging into this, all I did was think about the moment of impact. All I did was be like, how do I make the moment of impact better? And after a while, I realized that is actually too narrow of a question. If you've been in one of these high stakes moments. You recognize that we all get peripheral neglect. We get tunnel vision. We zoom in on one thing. We have to remember that there's a context and everything else out there, a very visceral memory for me, of having an unexpected cardiac arrest happen.

And I'm working it and assembling the team, and we have defibrillator pads on the guy, and you go into the defibrillator, the zappy thing, and you're charging it up, and you're getting ready to press the button. And the button is a big red button that has a lightning bolt on it. It's very clear that's the one you're supposed to press. And I couldn't find it. And I'm looking at this machine that's the size of two hands, and I couldn't find the big red button with a lightning bolt on it because I'm so hyper focused. Eventually, I found it. We shocked him, and he did great. That's the end of that story.

But the point is, I do this all the time. I train people how to do this, and still all of our brains have the same firing patterns in a lot of ways, and still I couldn't find it in the middle of it. And you have to slow yourself down and think about it. But I focused so much on the moment of impact that I neglected, temporally everything else that's happening before and after, just like you hyperfocus spatially a lot of times when you're under pressure.

So when I zoom out and think about this broader, to me, it's a loop. Prepare, perform, recover, evolve. Right? And you run that loop over and over and over again. Prepare, perform, recover, and evolve. And I actually think it's useful to take a second outside of emergency medicine and to think for a moment from a sports analogy, right?

So I do a little bit of work with the New Zealand Hurricanes, a great rugby team. If you just imagine them for a minute as a rugby squad, performance for them is game day. And you can get really granular. You know, maybe it's like doing a particular move or, you know, a particular situation, but really it's game day. Is their moment to perform. But if all you did was game day, game day, game day, game day, what do you think would happen to that team?

Jon Becker: Yeah, you're right.

Dr. Dan Dworkis: They'd fall apart. Their performance would suffer. They'd never make it to the next level of anything. Right. We know that's not how sports teams train. We know that. And if a sports team did that, man, you just think about what the chatter would be like on sports shows about that team that only did that. Everybody be like, you guys are idiots. But that's pretty much how we train a lot of the times. Perform, perform, perform, right? And somehow we think we're immune to it. Well, we are not.

So instead, if you zoom back out and think about it again, prepare, perform, recover, evolve. So preparation for that team is practice. And it's not just randomly doing things right, it's specific practice done deliberately to improve performance with metrics, with coaching, with watching, and with a plan.

Then you go to game day, you do the game day, and then after that you have recovery. And that recovery is what? Physical therapy, exercise, stretch, rest, like caloric intake. It's really letting yourself return to a baseline. It's discovery. It's asking yourself what happened watching the game tape, going home and resting, taking time out of that crisis mode. And then you get to evolution. Right? Okay, well, what do we do wrong? What do we do right? What are we going to do better?

Let's watch that game tape. Let's think about what happened. Let's dissect and really make sure we understand to the best that we can what went down and what's the gap between what went down and what we want to happen next. And that informs our next practice, and that practice informs our next performance, our next recovery and our next evolution. And you spin that wheel, and that is the virtuous cycle of applying knowledge under pressure when we do it, right?

So you take that whole framework and you map it back to an emergency. Right? Well, what's the thing I'm performing at? What's the decision I have to make? Okay, so one of the most important decisions for us is whether or not to intubate a patient to take their airway. Okay? That has all of those factors we talked about earlier. It's impactful, right? You have to breathe to live.

So if you take your airway and you don't do it right, they don't breathe and they don't live, that's bad for you. Right? It has pressure. There's a certain amount of time within which this decision has to be made and within which the skill has to be executed against. There's uncertainty because as much good as your planning is the phrase, the enemy always gets a vote.

Well, the patient always gets a vote, too, and their disease process gets a vote. There's other stuff that's happening that you don't understand and that you can't understand until you've already crossed that line. There's complexity, because the human body is an incredibly complex system with interlocking, interacting parts that have higher order complications to them. And there's liminality, which is that once you make that decision, you have to follow through with it. You have to move them all the way through and secure an airway in one way or another. Right?

So it has all those features of it. That's why I think it's a useful framework as a microcosm of what we do in emergency medicine. So everybody's probably seen it on tv, right? You know, like, okay, let's get prepared to intubate. And you get the tube and the thing and put the thing in the other thing, and it works out science. But, you know, so how do you make that decision? Right?

If that's performance, that decision and that skill set, that physical skill set, and that intellectual decision to execute on that skill set, if that's performance, what's the rest of the cycle look like? Okay, well, preparation is training, and you break it down into components. There's the physical skill set. Can you actually achieve the operational and technical skill required to perform this task? Well, that looks like.

Okay, here's how it does. Here's a mannequin. Get after it. Here's a harder mannequin. Get after it. Here's a harder mannequin with more challenges. Here. I'm going to give you this other thing. I'm going to hand it to you backwards. I'm going to hand it to you upside down. I'm going to yell at you while you do it. Right?

And you're really training the task itself. It also looks like the theory behind it. Endless, endless versions of tactical decision games. Endless versions of what would you do if this happened? Hey, watch that other person. They're doing this. How would you respond in their shoes, dissecting things and going forward and backward and lateral thinking to it. What if that patient in room three went down right now? How would you intubate them? Right. This constant back and forth that we challenge ourselves with. There's the moment of performance.

We'll zoom back into that in a second, but I'm going to avoid that for a moment. There's a moment of recovery, which is, okay, you've just intubated this person, and what happened? Are you okay? Did you stab yourself with a needle while you were doing it? Did the patient survive? What are your next skill sets that you need to immediately operate to make sure that they stay okay? Evolution. How do you get better at this task? Tomorrow than you are today. Right?

How are you going to learn from this intubation and make sure you and your team are better prepared to intubate the next person that comes in? Or was there something that went wrong, like the piece of equipment broke and your next job is to go fix that piece of equipment to make sure you're back on and ready to fire again. Right?

And you're spinning that cycle over and over again. So this whole deep, rich context exists within which you make one critical decision under pressure, which is, should I intubate this person? Does that make sense as sort of like a plan to go off of.

Jon Becker: It's interesting. It's actually a fantastic framework, and it's kind of like a derivative of the Ooda loop. Right? It's a fact. It's a fantastic. Because it, as you're describing that, I'm picturing that cycle as a series of russian nesting dolls.

Dr. Dan Dworkis: Sure.

Jon Becker: Right. So there's prepare, perform, recover, evolve right now with this task that I'm doing, but then there is a larger, more macroscopic cycle to that. So it's like, you know, if you. If you think of it in terms of a tactical operation, yeah. You're doing this thing right now. You're breaching a door. You know, you're preparing for that. You're figuring out what you're going to do. You're performing it. You're, you're, you know, either. Either clearing the way and then making movement and then, you know, learning from that experience.

But there is a greater, you know, cycle that's also in play, that is that same cycle. Like you are thinking macroscopically, we need to improve this set of skills. And as you're describing it, also, I'm seeing the kind of contrast between skills and training, learning to do something and education learning why you would do those things. Right? Understanding the why as opposed to the how. And all of that is going into preparation and all of that is underlying performance.

And, you know, if you think in terms of a team that is constantly having to perform, which, you know, an ER doc that's working really long hours, or, you know, a small SWAT team that's constantly having a high operational tempo, and you are going to perform to the exclusion of other things in a way that will eventually just degrade performance.

Dr. Dan Dworkis: And sometimes you just have to. Right. Sometimes you just have to. Right? Like, if you have a high op tempo because you're the only ones on call and you're it, like, you just have to go right. Like, we had a man, we had a day recently where we had a very tragic, super tragic infant death. And we were working on this infant for such a long time, and we just weren't able to get them back. You know, it just, I mean, there's – That's pretty brutal.

And, you know, my team was pouring their hearts out into this kid and the family. My family screaming as normal. And it's just a lot, right? And we're just making the decision to stop. You know, we've looked around the room and, you know, we've said, listen, folks, we're about at the point where we are running out of what our skills allow us to do.

In a moment, I'm gonna look around the room and I'm gonna ask everybody, what do you see that I don't? What do you see that we haven't tried? I need ideas that we haven't done yet. Give everybody a minute. You go around the room. Everybody, like, do you see it? Is there anything we're not doing? And you're just around. Everybody's like, no. We're like, this is it. Okay?

And we're making this decision to, you know, to pronounce this child dead. And my charge nurse taps me on the shoulder and says, dan, there's a seven year old with a gunshot wound to the chest coming in in 1 minute. You need to split your team, finish this, and get ready for that, kidde.

And, you know, this family that is suffering so much needs us to be in that room. Needs us to be consoling them, needs us to be there with their kid. But this other kid's family needs us just as much. And there is no recovery in that moment. There's no grace in that moment. There's no anything other than go to room, whatever, and get to work.

Jon Becker: Yeah.

Dr. Dan Dworkis: And the reality is we live in. We, you know, we operate in these worlds that do require that, and they require you to sacrifice of yourself to do that. And this is hopefully a theme that we're going to get to for some of our conversation. And this something we've been working on a lot in the mission critical team institute is the difference between service that requires sacrifice and service without self destruction. And those two things are often conflated and confused. Right?

A lot of folks from the outside of this world who aren't part of one of these tribes think that sacrifice is equivalent to self destruction, and it is not. It is not. We are prepared to sacrifice of ourselves to do our job, to hold the line, to protect our communities, you know, to keep the blood in the good people and out of the bad people, however you want to say it. Right? To do the stuff that we do. But that doesn't mean we have to self sacrifice. Excuse me. It doesn't mean we have to self destruct. Right?

And those moments where you are called upon to operate at such a crazy op tempo, you have to really distinguish them from the moments where it only feels like you have to operate at that tempo. Basically my point is, are you not recovering and not evolving because you really don't have time or because you just don't like doing it?

Jon Becker: Yeah. And it's funny because as you were saying, that's exactly what I was thinking. Right? Is the difference between self sacrifice and self destruction is recovery. Right? It is recovery that is that difference there and evolution. And so if we're constantly, if we're constantly in that fight, right. If we're constantly in that fight, we're not recovering, we're not evolving. And as you say that, like, there are circumstances where you don't have a choice, right? You don't have a choice.

But the kinds of people that are drawn towards those situations are also the kinds of people that enjoy those situations and as a result, tend to keep themselves in those situations and never take the time to recover and evolve. Right?

I have several friends who have just deployed and deployed and deployed and deployed and deployed. And they're like, well, you know, we need to go. And it's, you know, it's one of them put it best. It was Tom Satterlee at the point that the glass is empty, like, you don't have anything to give. You're not helpful in the fight when you're destroyed.

Dr. Dan Dworkis: You know, it's – There's a thing that happens. I feel like the name for it is paradoxical arousal. I'm not sure if that's, if I'm calling out the right term for that or not, but it's basically the point in time in which you spend so much time in that world that that's the only world that feels normal to you anymore.

Jon Becker: Yeah.

Dr. Dan Dworkis: And it's so much harder to go to the grocery store and do the laundry and have a conversation with your loved one. And it is in. It is so, it feels so much easier to just go back into the space. Right? I remember many times, certainly one of them being the early part of the pandemic, when thankfully, it wasn't as bad as we thought it was going to be. We were seeing reports of doctors dying and we sort of figured this would be our time to sacrifice of ourselves. I remember so clearly that it felt so much more comfortable being there than it did at home.

That is a real warning sign that your balance isn't quite right in there, that you need to really dig into your teams and get support from the other folks that understand that, that aren't going to tell you things like, just go take a walk, you'll be okay. Like, no, you need more than that. Right? Like, you need a community that understands what you're saying and that can be there for you to support you as you're going through that stuff.

And sometimes you need more than that. Sometimes you need therapy and you need help, and you need all sorts of things like that. And there's no. So there's nothing other than strength in recognizing when you need that and going after it.

Jon Becker: But I think as leaders, we need to be cognizant of that. Right? We need to have the macroscopic view of the people that work with us. And even as teammates, we need to go, man, this guy is grinding himself up here. We need to get him out of the fight and into the recovery and evolve.

Yeah. As you're describing, I'm thinking of, like, I do iron man, distance triathlon, and it's like, you know, exercise makes you stronger. Too much exercise destroys you. And it is that same thing. Like, if you don't take the time to recover and evolve, you're not. You're not preparing for the next fight. You're just dragging yourself to the next fight.

Dr. Dan Dworkis: Yeah, I think that's a great way to put it. That is, but. Okay, but we got to talk about performance, right? Cause we're sort of, like, talking about this whole structure of everything else around it. And we haven't really, like, we've set the stage for performance. We've talked about all the other things around it, but we got to dig in a little bit because I think it's important, and I want folks to come away from this with some things they can start doing right away.

So one of the things that we do the most when we're training this kind of stuff is the idea of applying graduated pressure. The model for this is a wedge. There's often things in training environments, in operational environments, that have what you'd call a step function of pressure. You go from some pressure to enormous amount of pressure. Right? Or you go from a little bit of hardness to astronomical hardness all at once.

And that's challenging for a number of reasons, but one of the reasons that it's challenging is that things break and you don't know why. Right? When you're trying to apply a skill that you are insufficiently trained at in an environment which is too fast paced and too challenging for you, things break and you don't know why. And that violates our underlying rule of you have to learn from everything.

So if you don't know why things broke and you can't get better from it, then something's wrong. Right? You know, I, well, at the, at the moment I have a knee injury so I have not been playing jujitsu, but usually when I play jujitsu, right, you see this, when you have a junior person go try to throw a move against a more senior person and it doesn't work and they have no idea why. By they I mean me. I have no idea why it didn't work, you know, so frequently. But the antidote is to instead apply graduated pressure to use a wedge instead of a step function.

Alright, well, so what does that look like? Well, let's go back to the idea of intubating. You're going to train that skill, that decision. Well, first you're going to break it into components. Okay. I'm going to take the tactical piece of actually putting a tube in a place and put it on one side.

Then I'm going to take the intellectual piece of. What are the medications I need to give to get that person's physiology optimized for the procedure? And I put that over here. Then I'm going to take, well, what about the post intubation care? Right after I put the tube in, how do I take care of their heart and lungs afterwards?

Jon Becker: Cool!

Dr. Dan Dworkis: I'm going to put that in a third bucket and I'm going to make as many buckets as I need about all the skill sets. I'm going to make sure that each one of them is ready to go. And you're going to do it in a low risk, low stake environment. Right? So again, you get this idea of a wedge. So if high wedge is full tempo, full, everything going low wedge is somewhere in the middle and that might be simulated environments.

There might be just one on one, high pressure discussions with a senior. Maybe that's going over things on a mannequin or, you know, in a shoot house or doing something like that where you're doing it in a much more controlled environment. Then you also have ultra, ultra low edge, which is low fidelity simulation, talking things through, tabletop exercises, stuff like that.

But the idea is that you take a skill, you dissect it. You do the pieces of it, and then you build it along that wedge on purpose until you're ready to deploy it when it actually needs to be done. And one of the commandments of this, right, is that you know where you are on the wedge and you're not just randomly doing things. Okay? You're not just mixing in.

All right, I'm going to do this skill on a mannequin, and then I'm going to actually go intubate ten people over here using medications that I've never tried before, and then I'm gonna go back and do it once. No, that doesn't make any sense. Right? You have an idea? Today, right now, I'm practicing this. I'm gonna do this, then I'm gonna expand it to this. Then I'm gonna expand it to that.

Jon Becker: Yeah. It's crawl walk, run.

Dr. Dan Dworkis: It's crawl walk we're on. But sometimes you got to go back and crawl better because you didn't get it right the first time.

Jon Becker: Right.

Dr. Dan Dworkis: Then you go back to walk, then you run a little bit, then you go back to walk, then you crawl, then you run, then you. Right. It's not necessarily a linear progression as much as it is. There are multiple points of time on a wedge, and you can use each of them constructively. Right?

So know what you're doing. And the second commandment of this is anytime you steer step function of pressure and complexity, try to put a wedge in there. Where in your team can you apply a wedge to that scenario? Can you build something in the middle that allows people the chance to practice that thing and learn from it so that when you get there, you're optimized to do it right. And if it doesn't go right, you have a better chance of understanding why it didn't go right.

Jon Becker: Yeah. Now that makes sense. Yeah. It's kind of like, instead of crawl walk, it's crawl crawl with your arm around somebody. Crawl with a walker gradually to take the big step out of it and make it a series of smaller. I mean, ultimately, everything is kind of a step, right? But, like, make the steps as small as you possibly can make them, and feel free to move forward and backwards in that process until you have mastered things before you do take that next big step.

Dr. Dan Dworkis: Yeah, well, I mean, again, this isn't rocket science, right. But, like, how do you learn something in jiu jitsu? How do you learn, you know, an arm bar or a guard escape or whatever it is, right? Okay. You do it slowly, you understand it, then you go back with your partner, and you each run through it a few times. You make sure you understand the positioning of everything, how it's supposed to work. Then you speed it up a little bit. You figure out what breaks, and you go back, you do it again.

Then you speed it up a little bit more. You figure out what breaks. You go back, you do it again. Then later on that day or that class, you try to apply the move in real life, you know, roles, and it probably doesn't work. And that's okay. And you figure it out, and you go back and you do it again. Right? Like, this isn't rocket science, but we don't do this in medicine. Sometimes we just throw people into the deep end and things break, and you don't know why. And that to me, is often avoidable if you put some work in ahead of time, in the preparation and performance phase of it.

Jon Becker: Well, what's interesting, too, about that is that when things break and you don't know why, you can't recover from it because you don't know what happened and you can't evolve from it because you don't understand why it broke.

Dr. Dan Dworkis: Yeah.

Jon Becker: There are times a cycle at each step.

Dr. Dan Dworkis: Yeah. And there are times when you just don't know. Right. You just don't know why something didn't work. And, like, okay, but that should probably be the minority. And you can at least get after some of those things that were leaving there, otherwise.

Jon Becker: Yeah, no, that makes a lot of sense. So, okay, so we've gone through kind of the macroscopic cycle. We're to the, like, the performance portion of the program. Talk to me about handling uncertainty and imperfection.

Dr. Dan Dworkis: Yeah. So I, you know, we are imperfect, right? We are all imperfect. I like to say I'm an imperfect person. Medicine is an imperfect art, and I practice it imperfectly. And if that's true, if all of that's true, the outcome is a little rough around the edges sometimes. And your job is continually to get better. Right? Your job is to get better. Your job is to learn. Your job is to keep pushing so you don't ever eliminate the uncertainty, though. It doesn't go away. You never reach a point of life where everything is certain and everything is perfect.

And if you're chasing that, you're probably pointing yourself in the wrong direction. Instead, your idea is, how do you function within uncertain environments? One of the things we talk about is the idea of bounded versus unbounded uncertainty. All right? Which is a really important distinction. So bounded versus unbounded uncertainty.

And a good, another sports metaphor here is basketball. So if you're playing basketball, you understand that your team and the other team is going to be five people. And you understand there are some rules to the game about how it goes. And when your group of five people gets on the court, you're not going to be facing a bear with a laser on its head and, you know, 16 sharks. You're going to be facing another group of people and they're going to be acting in sort of predictable ways, doing things that are maybe uncertain within that context, but it's really bounded, right?

So if you can figure out within the realm of uncertainty parts that are bounded, then you can train for and operate in those environments, right. If you can do that, then you can function more quickly in those uncertain spaces because they're ones that you can prepare for and activate ahead of time. So what's a good example of this? A common emergency is somebody having a seizure. Right?

Now, you can have a seizure for any number of reasons. It could be neurologic, it could be biochemical, it could be drug induced, it could be all sorts of stuff. But ultimately, no matter what reason they're having a seizure for, the problem is you got to keep them breathing when they have a seizure.

So the issue is you don't actually need to know the reason why at the beginning. You just need to do the stuff that helps them breathe while you're waiting for the rest of the certainty to appear, while you're waiting for the rest of the case to materialize, while you're waiting for more information to come in, make sure you're not getting stuck chasing uncertainty. That doesn't matter.

Jon Becker: One of the things we talk about in tactical decision making is you're never going to have perfect information. And sometimes the ability, sometimes you have 70 or 80% of the information you need to make the decision, and that's when you should make the decision. You can't wait till you get to 100%. Even if you get 100% of the information, it's already too late to make the decision, right?

But it's very easy to get your brain stuck in do loops where you're chasing some fact, some little piece of information that really doesn't drive the decision. It's just something, it's an off ramp that your brain takes and chases around.

Dr. Dan Dworkis: In circles because you want certainty. We tend to like certainty. Certainty is comforting. And to operate in spaces where we are uncertain is challenging. It's a skill, right? It's a skill that we're doing. So to have the ability to do that requires us to understand when, to not care about uncertainty, which is kind of a weird thing, right? So that requires enough of understanding of the context of what's happening, but even without the context, it just, you have to, you have to have your basic set of moves.

One of the EOD guys explained it to me this way. You want to use seconds to buy minutes, right. You want to do things that set yourself up for success, no matter what's going to happen next in those couple of seconds, that allows you to get more information coming in. So I don't really care why the guy's seizing at the beginning. All I care about is, can we get oxygen on him?

Jon Becker: Yeah.

Dr. Dan Dworkis: Can we get him in a place where he's not going to hurt himself? And can we get iv's established, can we get things that are going to make my next moves better when I figure out what those moves are? Right. Another great example of this is in a cardiac arrest, right? I'm not sure. Sometimes you have to shock somebody, sometimes you don't, depending on what their heart rhythm is. Right? But either way, you have to put defibrillator pads on them to even have the option of doing it.

So at the beginning, your job is not to eliminate the uncertainty. Your job is just put the pads on them, get yourself one step further down the line to the next place where you know how to operate and figure out the next move from there.

Jon Becker: Yeah, no, that makes a lot of sense. That makes a lot of sense. So how does that – Okay, so knowing, bounded and unbounded, how does that drive the way you approach a situation?

Dr. Dan Dworkis: One of the other sections is operating from first principles, and one of the biggest concepts, actually forget if it's in that section or not, but is the idea that there are dependencies in the way that things work. Right? So airway, breathing, circulation, why do we care about it? Usually in that order, although the march algorithm might be a little bit different. There's some other stuff that we won't talk about.

But assuming for a moment it's airway, breathing, circulation, you have to get oxygen into your brain to live, oxygen has to come from your lungs. Has to go from your lungs to your blood. Has to go from your blood to your brain. But to get to your lungs, it has to go through your airway. Right?

So if your airway is compromised, breathing and circulation don't matter. Even if they're perfect, they're never going to work. Right. If your breathing is compromised, your circulation doesn't matter because it's never going to work. Right?

So there are realities that underpin the way that we do stuff. And if you're able to hold those realities and operate from those principles, then you can approach these unknown situations in an order of operations that actually makes sense. Right?

So, okay. Somebody comes to me, they're down. I don't know anything about them or what's going on. All right, well, I'm going to make sure I work on their airway first because that's usually the right answer. Right? And you're moving, you're using whatever you know about the underlying reality and you're making the situation better as you're going forward with it.

Jon Becker: Well, it's just like major hemorrhage in a mass casualty. Right? Like, you know, step one, stop the massive bleed because that's going to, that's going to, they're going to die faster from that than they are from, you know, not having an airway, and they will die faster from not having an airway than they will from a circulatory problem.

And I just recently interviewed Claire Park, who's a doctor in London and former army doc, and she helped her write this ten second triage program that they were implementing all over the UK. And it's that thing, it's like the first thing you're looking at is are they walking? Because if they're walking, a lot of the stuff that's upstream that's going to kill them doesn't matter because it isn't doing, you know, we know it isn't that. And it's interesting because I think we are, we don't spend enough time thinking about these kinds of questions.

You know, in tactical law enforcement, they talk about priority of life or safety priorities, you know, and, and people say, well, you know, why would, why would you risk an officer's life, you know, to save a hostage? Because it's already pre decided that the hostages more valuable than the officer is and the officer is more valuable than the suspect is. And as a result, like those, those are, those are bounded. Right? We know, yeah, we know that. We'll make that.

Dr. Dan Dworkis: You can put some bounds on it ahead of time that allow you to, like, what are we really talking about here? We're getting in a cognitive load theory, right? We're saying that our brain has a set bandwidth and you can divide that bandwidth into buckets. There's the cognitive load that you're actually using to do the task that you need to do. There's the extraneous cognitive load that goes to other stuff in the environment, like people yelling or something itching you or something like that, that doesn't have anything to do with what you're doing.

And then there's German cognitive load, which is the part of your brain that's active trying to learn how to do a task better. Your job is to put as much cognitive load forward into the problem as you possibly. So you eliminate extraneous cognitive load and you separate out german cognitive load to training, leaving everything possible to actually solve the problem. So when you're describing that, putting bounds around uncertainty by making decisions ahead of time, that is decreasing cognitive load going anywhere other than the problem set well.

Jon Becker: And it's one of the things that's talked about a lot in our industry is front sight focused, right. You become front sight focused or front sight fixated. You know, you standing there in front of the defibrillator trying to find the red button is, is front sight focus, right? And the way you resolve that, that is your brain saying the load is too high. I'm going to ignore everything but this one thing, because this is the thing I think is important. And it doesn't mean it is the thing that's important. Right?

Dr. Dan Dworkis: Correct.

Jon Becker: Hopefully it is the thing that's important. Hopefully it is, you know, the suspect's hands and whether he has a gun to. But sometimes it's not. Sometimes it's something that isn't helpful. It's staring at the label on the defibrillator when you should be looking at the red button. And I think that we don't spend enough time thinking about that cognitive load and how we utilize the bandwidth that we have.

I interviewed a guy named Earl Plumlee, who's a medal of honor winner and had a just unbelievable shootout in Afghanistan, was given the Congressional Medal of Honor for it. But one of the things Earl talks about is they had trained the basics so much, right, the sight picture, shooting skill, reloading, that when he's in this horrific gunfight, and I would suggest you listen to the episode if you haven't listened to it, because it is – When I heard the story, I'm like, that's an action movie.

And I still don't believe it. It's that kind of story. And as he's describing it, though, one of the things he talked about was they were so drilled on the basics that they didn't have to do that. And he said, at one point, I'm in the gunfight and I see the brass coming out of my gun and I realize I'm too focused on my gun and I move my focus back to the attackers. And it's because he said we didn't have. He said, I resented when they taught me to do all these things. I resented everything that they taught me, and I hated the fact that they drilled these things over and over again.

But in the middle of this crisis, I was so good at the mechanical skills that they didn't matter. I didn't have to think about them. Right? You've intubated so many times that you only notice the physical act if it's something extremely unusual, which frees up that bandwidth, which frees up that cognitive ability and prevents you from becoming overloaded.

Dr. Dan Dworkis: Yeah. I don't know that we reach that level of expertise often in medicine. The things that we do. I mean, I guess there are things that we reach that level of expertise with. I don't know that intubating is one of them. I think that there are pieces of it that we reach that level of expertise with. Where you are, you're so into it that you're just doing the first couple motions automatically, like the way that I would respond to somebody who's seizing in front of me.

Now, I spend a lot of my time these days training junior doctors, and so I'm watching the way that they step forward into that problem set and start working it. But I think you're right. Like, you reach that level for some pieces of it. Maybe that just means I need to train more.

Jon Becker: Well, I mean, I do think that there are things that, you know, things like mechanical skills. I think you can build that level of proficiency. Right? You build that level of proficiency with driving. Right. When I started racing cars, of course, I tell the story. Like, the first seven laps on the track, I got out and laid down like my head was spinning, my brain was on fire. I had too many things to think about.

By the time I'm winning, all I'm thinking about is the guy in front of me, and I'm not thinking about driving the car anymore. Because the mechanical skills have progressed. Right. The reloading of the handgun, the basic skills. But that doesn't mean that you can do that with more complicated things. Right?

So much of medicine is you're having to diagnose complicated problems, and in a tactical situation, you're having to diagnose. I mean, you think about a Dev Grusille entering a hostile facility in a hostage rescue. Like, his brain is processing thousands of data points. And in many cases, what separates the one that is very good at it from the one that isn't very good at it is that ability to prioritize, that ability to recognize the stuff that matters. So you can't solve it all, but you can become extremely proficient at the skills part of it, which at least takes it out of your bandwidth.

Dr. Dan Dworkis: Yeah. And I think that you can do a lot of work to eliminate the unnecessary pieces of it. Right? I think that's a really important piece of it, which is that, like, even as you're training to get better at a task, you should also be training to eliminate the unnecessary ways that you fail. Right? And that's a constant battle in systems that are imperfect, that are almost antagonistic in their ability to screw things up for you, but you have to be always taking things away from that. Right?

There's a story I tell in the book about, you know, we had just done this really incredible, very challenging intubation of this very sick woman who had a bunch of lung disease, and her oxygen level is really low and was very challenging task, but we succeeded at it, and we're getting her up to the ICU only to find out that her oxygen levels start crashing. Something's wrong.

Get her back in the room. Let's get her back on the – Figure everything out. The punchline is nobody had double checked that the oxygen cylinder under the bed was full. Moving her to the ICU on an empty oxygen cylinder. Right? So you did the hard part. Right? And you still get tripped by the easy part because it's an unnecessary opportunity for failure. Can you actively get after and eliminate those things that'll make your performance much better as you're learning how to do.

Jon Becker: It – which is preparation. Right? Like that. A lot of that is preparation and creating systems that are failure resistant. It is creating. Whoever is supposed to check that oxygen cylinder checks it all the time, and it's never empty, so it's never a failure point.

Dr. Dan Dworkis: But this is so interesting, right? Because there's an answer to this problem set that we're describing, which is now you have a checklist before you move somebody from the ER to the ICU, and it has ten things on it, you got to check these critical things. And that's an answer. That's an answer that's usable and worthwhile in some cases. But you can't create an exhaustive checklist for everything, right? Training versus education.

There's just no way for you to actively predict every single thing that's going to go wrong with any degree of certainty. Go build a checklist for it and fiat and mandate from above. This is how we do everything in there. We don't want automatons. We want educated operators that are able to improvise. Because once you enter those liminal spaces, you're going to find things that haven't been thought of before. And if it's not a checklist and all you do is checklist, you're going to run into some issues in there.

Jon Becker: Yeah. I mean, I'm sure you read Atul Gawande's books, right? Like it? Yeah, there is. Checklists are fantastic for things to prevent you from forgetting them. But one of the things we went through when we went through ISO certification is one of the things you try to identify is all the ways that you can make a mistake that will lead to a failure in the product, which is impossible.

But the exercise of doing it, you start to realize, okay, well, these things can go wrong, and the whole goal is to intercept those things upstream. Right? It's to make sure that not the doctor is making sure the oxygen cylinder is full, but that there's a guy whose job it is to make sure that everything mechanical is at a certain level, and he is the one that's running the checklist and regularly, every day. Okay. It's kind of like fire extinguishers, right?

Somebody's inspecting the fire extinguishers because when you need the fire extinguisher, it's not the time to figure out the fire extinguisher is dead.

Dr. Dan Dworkis: Yeah. But there's also the idea that when I'm leading a team, part of my ethos has to be, okay. I might not be the one checking the oxygen tank, but my job is to tell this story about the oxygen tank so that everybody else is like, ro, right? What are other things that are like that? What's the oxygen tank in this situation? How can I make the feel a little better for it? You think about the idea of the principles of leave no trace camping. You're going to leave the campsite as good, if not better, than when you found it, and hopefully better than when you found it.

So I want a group of, I want a team that leaves that emergency department better than when they found it. Every shift, every time. I want that to be the ethos of what we're practicing for it. And that story is part of how you get to that. You're like, hey, this thing happened. What do we do about that? And you don't stop at the answer of fill the oxygen tank because, like, sure, but like, what's the underlying thing?

The only thing is we didn't have a culture where everybody checked that ahead of time. We didn't have the right space in there where people were really digging into it. We're proactively going after it, and we're trying to make that happen in a sense that really mattered. And. That's not. That's not quite wasting suffering, but it's getting pretty d*** close to wasting suffering. It's certainly not doing everything we can to learn from what's happening and progressing in that manner for it.

Jon Becker: So it's also this notion of interrupting failure as far up the funnel as you can. Right. It's trying to catch it before it is something you're having to think about. And I don't think there is enough attention paid to that, because when you go back to the limited bandwidth we have available, if you're spending your bandwidth on stuff we could have prevented, and through simple inspection and mechanical means, we are decreasing the likelihood that you're going to perform. Right? If you're having weapon failures in the middle of an operation, we've added chaos that we didn't have to add.

Dr. Dan Dworkis: Yeah, yeah, I think that's very fair. And there's a medicine concept that basically is like – Basically like healthy people in healthy communities supported by healthy systems is what our goal is. Right? And I think that maps pretty well to what you're describing, which is that we want operators capable of performing in crisis, surrounded by teams that support them as they perform in crisis, wrapped up in systems that make it easy for them to succeed in crisis. Right?

And when you have that construct and that chain and everything else, then you have the ability to really, really, really push the boundaries of what's possible. Then we're getting towards what excellence looks like. And the further you are away from that vision of it, that's where you're starting to bend the curve wherever you can to try to match that. Your individual ability to change that situation might differ depending on your spot on the team or your seniority or your whatever it is.

But whoever you are on the team, you probably have the ability to make the environment right around you a little better for the people, a little better for the team, and a little better for the system. And I think that is part of our job. Right? Our job is not to solve every single problem. Right? We didn't design, like, to your point, we didn't design the weapons, we didn't do the things. We don't have to be a master of everything, but we have to, if we really want to perform under pressure, we have to be a master of the local universe. Around us such that we are always improving our situation and always making it easy for ourselves to do the right thing, or at least easier.

Jon Becker: Yeah, but you raise a really interesting point which ties into the book, which is this notion of balancing competing forces. We are always under attack from 100 different directions. And I think that does make us. It makes it difficult to perform at an optimal level.

Dr. Dan Dworkis: Yeah, absolutely. So one of the things we talk about in that section that I think is so important is the forest and the leaf idea, sort of going back and forth between micro focus totally devoted to one concept and a macro view of the whole field and everybody that you're doing. And we've talked about this idea a couple of times when it goes wrong, right terms of, like, hyper focusing on the, the defibrillator button.

But that idea of, are you really spending your energy on a specific, tiny subset of some problem, or is your energy better spent in that moment with a. With a tactical overview of what you're doing? And realistically, most of us in these worlds have to go back and forth between those two views. Right?

There's a certain skill set that we do. You know, a central line where you're really threading a several millimeter thick wire through just slightly larger than that catheter in order to put this large line into the person's, you know, jugular vein or femoral vein or whatever. And that is slippery and hard and requires your entire attention to get it right. But not everything is like that. And you really have to go back and forth between that and the whole system. Am I doing the right thing? Should I be doing this in the right way? What does this patient need? What does the patient, room six, when I'm in room eight, need? And how do you balance back and forth in that?

And one of the things that we work on in order to get better at that skill is this concept of basically heads up, heads down, heads up. Right? So if you're about to go heads down into a thing that you know is going to take your attention into a single point and focus, you want to try to get in this pattern of heads up, heads down, heads up.

So right before you go heads down, you take one last look around and make sure everything is as best as it can be, and this is still the right thing to do. You let your team know you're going heads down. Probably that means transferring command or prime in the room to somebody else. Right. Then you're doing your task heads down.

And when your task is done, you make a super conscious effort to go immediately heads back up and look at everything else that's happening. You cone your focus in, you cone your focus back out. It's a easy and predictable way to fail at zooming back out after you've been hyper focused. Right? So can you drill that and pattern that and work on that to eliminate that chance of failure?

Jon Becker: Yeah. It's not unlike. One of the things that is taught in shooting is the idea that after you engage, after you shoot, the idea of coming back to a low ready and looking around. Right? And it's that same thing. You are moving from the sights, from the immediate prospect, the immediate thing that you're threatened with, because that's going to get your attention, it's going to hyper focus your attention because of the adrenaline and everything else, to, okay, gun down, look around, zoom back out. Right?

So it's to the equivalent of heads up. And I think that's a really interesting way to describe it, is, you know, you are making a conscious decision, and even, even as a physical practice of physically stepping back, putting your head up, like physically looking around the room, gives you that ability to regain some, at least operational perspective from the tactical thing that you were engaged with. Yeah.

Dr. Dan Dworkis: And we've been focusing mostly in this conversation about the individual operator level, less so on the team and the system around them. But when you think about how a team does this, what's implicit, what does a team need to be able to do when one person goes heads down to accomplish a skill that needs that, the team has to know that's happening. They have to be aware of the shift in focus, they have to be aware of the shift in leadership, and they have to transition well and skillfully between those two points.

So we talked earlier about intubation. Right? Intubation is a very highly skilled event. Typically, there's a different person who's running the intubation than a person who's running the resuscitation as a whole. We divide and conquer in that way for various reasons. But when it's the person who's actively intubating, they need to make certain sets of decisions. They need to pass command back and forth.

And if the person who's running the show has to go back them up, which does happen sometimes, then the whole rest of the room needs to know. Oh, actually, now John's in charge. Dan's going to move to the head of the bed and take over the intubation. So how do you run that piece of it? Not to sound like a broken record. Right?

But the answer is, prepare, perform, recover, and evolve. You drill it ahead of time, you operate on it, you return command back to the person that needs it afterwards. That's your recovery phase. And then one of the things you debrief on the other end of it is, hey, we had a situation where we had to transfer command partway through a really challenging situation. Did that go okay?

Jon Becker: What can we learn from that? Well, and it's also. It's also, you know, understanding that that is a limitation of human beings and making a conscious decision to affirmatively take that. Like, I remember when we first had our kids, we. It was right after the Tommy Lee incident where the kid drowned at Tommy Lee's house.

And there was all this talk about, you know, well, how could parents not be watching their kids? And my wife and I made a conscious decision that anytime we were watching the kids, one of us was watching the kid. It wasn't both of us. We were never both watching the kid. One of us was watching the kids, and we were going to affirmatively hand it off.

So it's like, I'm handing you, you know, I'm going inside the house. You have the baby. I have the baby. And if there wasn't and I have the baby, then nobody had the baby. Right? Because the kid drowns in the pool. Because nobody's watching the baby, but everybody thinks the other person is.

And that's kind of what you're talking about, is this notion of like, okay, I'm going to go and hyper focus on this one task of intubation, or I'm the guy setting the breaching charge. Somebody else has to take over the larger perspective here and maintain as a team that the whole team doesn't lose focus. Right? The whole team doesn't become frontside focused.

Dr. Dan Dworkis: So one of the many interesting problem sets that we get to work on as emergency doctors is often, as an ER doctor, you'll be the only doctor in an emergency department. And depending on the size of the hospital, there are times when you'll be the only doctor in the entire hospital. Right? So you're surrounded by an incredible team of nurses, an incredible team of techs, people that are getting after it and want to do good work and are amazing folks, but you're the only doctor.

And so when you go heads down, there are no other doctors to hand command off to. So you have to be incredibly skillful with your team in order to say, okay, here's what we're going to need to have happen as much as possible. Let me clue you in on what I'm thinking. And part of your job in that situation is not just to be able to do the skill and be able to run the resuscitation, but also to elevate the level of everybody that you're playing with. Right? Because they're all going to have to play up because you're heads down doing a thing that only you can do.

So you need them to be able to do all sorts of other skills. So there's this incredibly. And, you know, the times that I've been fortunate enough to work in those kind of environments, the people have been amazing. Right? Just awesome! And it's an incredible situation to work with. It's also super challenging. Right? You have to be paying attention to these crazy number of variables. Everybody's doing things they might not necessarily be comfortable with or have done before, and everybody has to play up.

Jon Becker: Yeah. Well, I don't want to run out of time with you here. I want to talk, kind of jump ahead a little bit and talk about kind of your work with MCTI. Why don't we start with the definition for those that don't know MCTI. Kind of what it is and what they do.

Dr. Dan Dworkis: Absolutely. So the mission critical team institute, we existed at the request of mission critical teams, which are small groups of what we would call indigenously trained operators who make life or death decisions in timeframes that are often 500 seconds or less. That is what you do, and that is what I do, and that is what I would imagine a lot of the folks listening to this do. The indigenously trained part is the part that sometimes trips people up.

So that's worth talking about for a second. What that means is it's not something you can learn from a classroom room. Right? You can go to school to understand the ideas, but you are trained by people that are actively doing it. There's a long line of folks that are doing the job, that are then training you to do the job, and then eventually you become the one training the next person to do the job. Right? That's what that piece of it means.

So emergency medicine would certainly qualify under that characteristic. We make life or death decisions. You go back and forth between the ordinary and the extraordinary world. Like we talked about earlier, the mission that we have called the s three mission, we exist to promote the success, survivability and sustainability of these mission critical teams. Those are really three different and incredibly important things. We got to be good at our job, but we got to live and we got to be able to do it for a long time and train the people that are coming behind us.

Jon Becker: I first became aware of MCTI through their work with one of the tier one units and another national level asset. What's your role within MCTI?

Dr. Dan Dworkis: So, I am the chief medical officer of MCTI, building out at the moment the mission critical medicine group. So, applying these concepts back to medicine and really expanding a lot of the work that I've done with the emergency mind project into more of the small group teams operating under pressure in medicine.

Functionally, that means we work with medical teams that operate in mission critical environments and also the other direction, mission critical teams that are performing a medical skill set or operating in a medical capacity. So we do some medicine and some, you know, not otherwise specified.

Jon Becker: Got it. What is your work at MCTI taught you that you think would be valuable for a tactical audience to know? Like, kind of, what are your top lessons learned out of MCTI that you think that our users could walk away learning?

Dr. Dan Dworkis: The biggest thing is pretty abstract, so I'll try to pair that up with a slightly more, you know, grounded version of it. But the most abstract thing is that the problem sets that you are facing are pretty similar to the problem sets that other types of mission critical teams are facing. And we are stronger together than we are apart. Right? S

o if you are trying to figure out how to balance the stuff that you're doing, trying to figure out how to apply some of these concepts we've talked about, one of the best things you can do is get together with other high operating teams and talk through some of these ideas, because you're going to find stuff that fire's doing that law enforcement never thought of. You're going to find stuff that NASA is doing that ER, doctors never thought of. You're going to find when you approach these problem sets from various directions, you're going to get just absolute high output growth and power from it.

Jon Becker: It's one of the things I love about what NCTI is doing. I've interviewed several people that are on the periphery of what we do. Bob Kuntz is a nuclear submarine commander, Gareth Locke, who is working on diving air, trying to eliminate human air diving. And every one of those conversations, I walk away thinking, man, I had not even. I didn't think that they understood that the way that I understand it or the way my end user listener understands it, it is fascinating. You can't be a prophet on your own village, but frequently the village that you think would not have a profit for you does, you know? Yeah.

It's the guys down the river where you're like, those guys don't know what they're talking about. Sometimes they really do. Sometimes, you know, sometimes there are lessons to be learned about business from airplane pilots.

Dr. Dan Dworkis: Listen, one of the big concepts I was taught coming up is that the room is always smarter than any one person in it.

Jon Becker: Yeah.

Dr. Dan Dworkis: Right. So that's true. Doesn't matter how smart of a doctor you are, the room collectively is smarter than you. They're better than you. And your job, leading resuscitation is to get your entire room facing the same problem set and working. Working on it together. Right? That makes the difference between life and death more than almost anything. Same thing's true when you think about these mission critical teams. Right? Collectively, we are smarter than any of us alone.

Jon Becker: But I think it is a challenge for many of us who are alpha males and who are in positions of authority and positions of responsibility. You are very inclined to believe that because you are the doctor, it's all on you. And so you have to be the guy with the answer as opposed to being the guy who finds the answer.

Dr. Dan Dworkis: I guess I'm a little lucky in that sense that medicine is so d*** hard, right? So many things go wrong and you lose so many things that it disabuses you of the notion pretty d*** quickly that you are invincible and, you know, capable of having all the answers. Right? You know, you. You talk to a family of a. Of a child that died when your team did their best and did everything they could, and the child still dies. You know, you don't walk away from that thinking that you have the answers to everything in the world. Right?

You walk away from that, realizing, all, right, I'm gonna do better tomorrow, and I'm gonna look everywhere I possibly can to get this team better than where it is right now. My suspicion is that a lot of folks listening to this, like, you know, I hope you haven't gone through that piece of it, but probably you've gone through something parallel and you've walked away from a situation being like, wow, that was. That wasn't where I wanted it to be.

Jon Becker: But I think one of the things that separates people that go through trauma and never recover and people go through trauma and are better, is that introspection. It is that moment of, what can I do to not feel this way again? And the willingness to seek counsel, whether it's technical counsel, emotional counsel, or just somebody that understands. I think we do have to humble ourselves and be willing to recognize that we don't have the answers. And ultimately, the team is always stronger than the individual.

Dr. Dan Dworkis: And it's a weird, fun balance, too, right? Because you have to be humble. You have to be able to look at yourself and be like, I am imperfect. And then you also have to be able to be like, I am going to charge into that next room as fast as I possibly can and do what needs to be done. This is what I always tell my residents when I'm training them to run cardiac arrest for the first time. I'm like, you are humanity's best hope, right? You are the sum total of everything that humankind has ever invented about medicine at the tip of the spear, and it's you today.

And it's imperfect because we're not there yet. We haven't fixed all these problems yet. And it's a challenge and it's going to suck. And you're not going to do everything you want to do. And you have to believe that you are humanity's best hope when you walk in that room. You have to somehow balance both of those.

Jon Becker: Yeah. And it is a difficult balance. I think that's a good place for us to stop because I think you and I could probably talk for about 14 hours.

Dr. Dan Dworkis: Yeah, absolutely.

Jon Becker: I want to get to our five final questions, but before we do that, how can people find your work?

Dr. Dan Dworkis: Absolutely. So the emergency mind project is out there. It's really easy to find. It's and I am, which is the easiest way to reach me. The mission critical team institute is out there also. We are, and you can connect with us and look us up through all of that. And we're always, always open to talking to all sorts of folks in this world.

Jon Becker: What I'll do is I'll add those to the notes to the show notes so people can just click on them. All right, let's do the five rapid fire questions. This is a way I like to end with all of my guests like you, who I think can make us smarter short answer questions. First thing that comes to mind, whats your most important habit?

Dr. Dan Dworkis: My most important habit is pausing and reflecting. Right? Recognizing that the first thing I think, ironically for this rapid fire question section is that the first thing I think of might not actually be the real answer and separating out the stuff that happens from what I actually want my action and beliefs to be.

Jon Becker: What's your current favorite online resource? Website? Podcast? Like, what's your latest intellectual jam, so to speak?

Dr. Dan Dworkis: Yeah, I've been reading a lot of this stuff around red teaming lately. I think that's been super fascinating, that's drifted a little bit into some business stuff. I've been listening to invest with the best podcast, which is a bit of a weird resource and probably not something that a lot of folks in the tactical community are hitting on.

But you look at these people that have built these incredibly efficient systems at how to do stuff, and how did they get from inefficiency to efficiency? There's a lot to learn from that group in terms of how we can build the systems around us better.

Jon Becker: What's the most important characteristic of an effective leader?

Dr. Dan Dworkis: Curiosity. Coupled with that sense of never wasting, suffering.

Jon Becker: What's something you've changed your mind about in the last few years.

Dr. Dan Dworkis: Man, how long do you have? There's so much. I mean, I think one of the big ones that we talked about earlier was the sense that performance is a moment separate from the rest of the context about it. I really thought if I just pushed better, harder and faster, I'd get things done. And now I'm so much more interested in and curious about the rest of that loop about, you know, prepare, perform, recover, and evolve. That's made a big difference in my ability to do the job that I do.

Jon Becker: Final question. What's the most profound memory of your career?

Dr. Dan Dworkis: There's a hallway, a brick lined hallway that heads into the ER at Mass Gen, where I did most of my training. And, you know, mass general is like a million years old, right? Those bricks were probably around before anesthesia was around. It's only a slight exaggeration because it's an old hospital. There's a sense of history to it. There's a sense of purpose to it.

And that hallway leading into the resuscitation area, when I first started doing that work, I'd get really nervous walking in there. I'd be like, how am I going to perform today? How am I going to do this? What am I going to do? And I made a conscious decision at some point to every time I walk through that hallway, getting ready to go into that space to think about, there's this one line from the hippocratic oath which says, into whatever house you enter, may it be for the good of the people within.

And I made this decision that I would say that to myself when I walked down that one brick hallway. I am not perfect. I don't have to have everything exactly right. But I will swear that when I walk into this space into my home in the ER. It will be for the good of the people in there. And that is how I'll judge myself. And if I do that, that's how I'll judge my life as a human being. And that hallway image is just, like, seared into my brain from doing that walk so many times and making that commitment over and over again to try to bring something good to the people in there.

Jon Becker: Dan, I can't thank you enough for doing this, man! I am glad you made that commitment, and we are all better because of it. So thank you so much for being with me today!

Dr. Dan Dworkis: Well, Jon, thank you so much!

And for the folks listening to this, I just want to say again what I said at the beginning, that we're on the same side of this problem set. Looking at it together. You know, I need your help and your ideas, and so do my patience. And I'm looking forward to hearing from you all.

Good luck out there!