Millennia ago, before cannons and flintlocks, sabre-toothed tigers stalked our ancestors. Like most creatures of prey, Darwinian evolution led us to adapt to threats like tigers. We learned to run from danger or, when running wasn’t an option, to defend ourselves to the end. This was not only a mindset innate to humans, but a complex biochemical response: when faced with danger, hormones flood the body, blood delivery to muscles is prioritized, senses are heightened. This response, the Flight or Fight response, is triggered in a small part of our brain termed the amygdala.
Fortunately, sabre-toothed tigers don’t roam modern-day streets. Our bodies, however, haven’t caught up to this reality; the amygdala is standing ready to superhumanize our bodies should our survival be in question. The amygdala works at lightening speed: it bypasses the frontal cortex, where options are considered and debated based on reason and fact, in favour of instinct. Located deep in the part of the brain we share with prehistoric reptiles, the amygdala causes us to react to stress. Sometimes, that stress can be maladaptive, harming us more than it helps. In that sense, our amygdala hijacks our brain, sending our heartrate through the roof and filling our stomach with butterflies.
If you work in a high-stress environment that demands high performance, the amygdala hijack can be deadly. SWAT team snipers, Navy SEALs, 911 operators and emergency workers all face high-stress situations yet must remain level-headed. The conundrum? We are trained to listen to the amygdala! Pattern recognition allows for fast reactions to new information. Secret service agents scan crowds for suspicious patterns just as emergency physicians can spot a heart attack patient from the other side of the room. This allows our mind to pick out problem patterns that are dangerous – to the president, to the patient, to us – and put us on an instinctive reactive pathway.
And this is where the system falls apart; once the hairs on the back of our necks go up and we have been alerted to a threat, we have to quickly overcome the amygdala and analyze the situation. See, the amygdala overcalls threats. A car backfires, and you startle. A plane has some turbulence, and you grip the armrests. We react a little too often to stimuli that the amygdala interprets as threats, but actually aren’t.
The trick, then, is to know how to control the physiologic response set off by the peptides coursing through your veins once the amygdala sounds the alarm. Rather than react immediately, we must suppress that crocodile-brain of ours and activate our frontal cortex, the part of the brain that makes us smarter than every other species on the planet. Except maybe dolphins, I hear they are pretty smart, and they’ve never voted to leave the EU… but I digress.
Whenever I feel my amygdala taking over, I repeat a calming mantra to myself:
Pause, Reflect, Respond.
The amygdala short-circuits the frontal cortex in favour of immediate, instinctive action. My job is to take that intuitive signal and check it against the facts. I pause. I regain control of my brain, quite deliberately, by switching off the hormonal response. A slow, deep breath in pushes the diaphragm downwards, activating the vagus nerve. The vagus nerve activates the parasympathetic nervous system, reversing the effects of the amygdala hijack. Holding the breath stimulates baroreceptors, sending calming signals to the brain. Nodes in the heart are stimulated to slow, epinephrine is moped up and cleared out, and the fog of fear clears from the mind, restoring the analytic abilities of the frontal cortex.
Alerted to danger and ready to think, the next step after pausing is to reflect. Are the facts that I am seeing congruent with the emotions triggered by the amygdala? Is the threat real? Can I obtain more data to confirm my intuition? Some of this will seem very familiar to work done on the psychology of clinical decision making championed by Nova Scotian Pat Crosskerry, and it is! You can check out some of his work if you are more curious on how health care workers think.
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Now that I have considered the information, I can respond to the situation. Note the word “respond” rather than “react”. A reaction is quick, instinctive; a response is slow, considered. That’s not entirely true… skilled and experienced health care workers can experience an amygdala alert, pause, reflect, and respond, in milliseconds – but only because they have trained their brain to do so.
Pause, Reflect, Respond is of course oversimplistic. Pausing, I find, is incredibly challenging when the stakes are high and a room full of people are looking to you for leadership and direction. Reflecting involves teasing out reality from my own perception of reality, where cognitive and social biases are deeply rooted. Responding requires confidence and ability, something I am still developing as a junior doctor, and negative self-talk, self-doubt and “impostor syndrome” frequently scare me away from a plan of action in favour of deferring to others, a feeling that I don’t (anymore) have when I work on the helicopter (and one of the key reasons I continue to do so). I am practiced at Pause-Reflect-Respond to nearly any situation I come across on the helicopter, but in the emergency department, it’s a different ball game.
Lastly, while clinical analysis is our core job, emotional intelligence is what really gets the job done. Being able to lead a team to achieve the goals required to treat a heart attack patient is as essential as knowing how to identify and treat a heart attack. Pause-Reflect-Respond applies to this realm of medicine also; understanding the state of your team, and being able to modify it to achieve higher performance, is the hallmark of an effective emergency physician.
The amygdala hijack causes smart people to do dumb things. By pausing, reflecting and responding to stressful situations, we get the best of both worlds; accessing our past experiences while analyzing new ones helps us utilize our entire mind to best lead teams to perform at their very best. High performance teams freed of the amygdala hijack –be it on the battlefield, in the cockpit, or in a resuscitation bay – save lives.
Are you good at controlling the Amygdala Hijack? Do you have the tendency to: -be deliberate and apt to survey a situation before responding? -control your emotions? -resist impulse under times of stress? -describe yourself as emotionally neutral? -not allow emotions to colour reality?