What the ER Can Teach Us About Leading Under Stress

What if the key to performing under pressure… was slowing down?

Stanford emergency physician Dr. Al’ai Alvarez and critical care nurse Sara Marrello have faced the highest stakes imaginable—code blues, trauma resuscitations, life-or-death calls made in seconds. But the mindset that keeps them steady? It’s not what most people expect.

In this episode, we explore how elite ER teams make split-second decisions with calm precision—plus how business leaders can train for the same resilience and clarity in high-pressure moments.

Connect with Dr. Al'ai:

💼LinkedIn: https://www.linkedin.com/in/al-ai-alvarez-722980119/

✖️ X (Twitter): https://x.com/alvarezzzy

Follow me for more:

🌐 Website: www.toughness.com

📸 Instagram: @paddysgram

💼 LinkedIn: Paddy Steinfort

✖️ X (Twitter): @paddysx

 

 

Transcript:

[00:00:00] Dr. Al'ai Alvarez: Emergency medicine is being able to handle anyone anywhere, anytime. 

[00:00:04] Sara Marrello: You can't give your full attention to patient B if you are still figuring out what you should have done with patient. A, 

[00:00:10] Dr. Al'ai Alvarez: the key for me is being able to take care of all of those patients and finding a moment to simply debrief 

[00:00:17] Sara Marrello: For our residents ,it's a growth thing for them to be like, like you can sometimes win. 

[00:00:29] Paddy Steinfort: Welcome to the Toughness podcast. I'm your host, Paddy Steinford, and today we have a couple of guests that are from a world that most of us can't imagine. Two emergency medical professionals, both equally important in their own right. Welcome to the show, Sara Marrello, who is an ER nurse and critical care nurse from Stanford.

[00:00:50] Sara Marrello: Welcome. Thank you. 

[00:00:51] Paddy Steinfort: And Al’ai Alvarez who is also an emergency medical professional, but he's an emergency physician. Also from Stanford and you have a few other titles Al’ai that I'm not gonna list off. You do run the residency program there as well. I wanted the assistant residency program, directors, uh, for the, uh, training program.

It's great to have you both. This is obviously a, a time in, in all of our lives when medical professionals are all of a sudden much more important to us than we thought a year ago. But particularly with reference to what we talk about on this show, it's gonna be really cool to dig into the sort of stuff that you and your teams deal with on a daily basis that are just things most of us can't comprehend.

I know that Sara, you've just finished a night shift, I believe. Yep. And what time did you clock off? 

[00:01:35] Sara Marrello: I clock off at 8:00 AM and then I woke up so that I could talk with you guys and then I'm gonna go back to bed 'cause I gotta clock back in again at 7:30 tonight. 

[00:01:43] Paddy Steinfort: Wow. Well, we, I, I feel blessed, I feel honored and I I very much appreciate it. I'll have to buy you a a cup of extra cup of Joe whenever I can get to San Francisco next. 

[00:01:53] Sara Marrello: We appreciate it. 

[00:01:55] Paddy Steinfort: Tell us a little about, so overnight, give us an example of the sort of emergency situations that you might face, say in the last 24 hours in this last night shift. What was the ER department like at Stanford? What are the sort of things you have to deal with in a standard shift? 

[00:02:11] Sara Marrello: So my role is a little unique in that I kind of survey what's going on in the department and I watch to see if there are people who are kind of standing out to me as sicker than others. And then I touch base with the nurses and the physicians and see if there's anything I can do to help. So in the last 24 hours we had a couple of patients who transferred in from outside hospitals for the specialty services we have at Stanford. Most of them with low blood pressure, one with a traumatic eye injury. It was just kind of a typical night in the emergency department. Very exciting. Always. But that's what we were working on last night.

[00:02:44] Paddy Steinfort: Right. And, and in that, in those typical nights, I'm using air quotes there 'cause I'm not sure if there is such a thing for those of us who've never stepped in there or who have accidentally stepped in there on a gurney, how often would you get to a point where it's like, okay, this is actually life critical, we could lose a human being here?

[00:03:00] Sara Marrello: I would say at an emergency department this size of Stanford every night we have those moments Yeah. Where your stomach sort of flips over and you're like, oh, we need to, to be here now, we need to move a little bit faster. We need to, we need to go, go a little bit harder on this one. And the key is to try and recognize 'em early or hope that somebody has recognized it early. And if it's late in the game, then we usually are scrambling to get our feet underneath this, um, and hopefully turn things around. 

[00:03:24] Dr. Al'ai Alvarez: Yeah, Paddy, lemme give you a perspective as well. Yeah, go ahead. The emergency department is the size of a football field, literally, and so the format at Stanford, for instance, is that our critical care area, it fluctuates from, it's not fixed in one part of the emergency department, although one area tend to receive a lot of the resuscitation, which highlights the role of Sara, for instance.

They are really trying to sniff out the critical care patients in the entire football zone, and so they're not just isolated in one corner of that football field. They have to track all of the patients in our board. See if any of the vital signs are really heading towards critical area, area. And then the team that Sara runs will then kind of jump in and say, Hey, what's going on here? What can we do? What can we help? And that's the model of our critical care team in the emergency department at Stanford. 

[00:04:16] Paddy Steinfort: Yeah. And, and that's a, uh, really good tangible reference point there. The size of a football field, like, yeah, imagine I, I'm already picturing trying to run from one enzyme to the other.

[00:04:25] Dr. Al'ai Alvarez: And I don't run, so I, I'm, I'm usually in one zone, so I run one, I'd say maybe like an eighth of that zone. And Sara's team, they're flexible. They go from different places and that's why when I mentioned earlier that when we get those resuscitation, it is such a breath of fresh air. When I see faces like Sara, it's like, oh, this is gonna be a great resuscitation.

[00:04:46] Sara Marrello: I will tell you though, if I were to ever see you running Dr. Alvarez, I wouldn't even need to know what would be happening Exactly right behind you. There's not a lot that makes us run in the emergency department. 

[00:04:55] Paddy Steinfort: No. 

[00:04:56] Sara Marrello: I think on the TV shows, it looks like we run all the time, but the truth is, is when people see people running for like no reason, we're like, why are you running? Don't run. Why are you running?

[00:05:03] Paddy Steinfort: Yeah, exactly. That's a really, really important point. How much is that a natural, inbuilt part of an emergency physician or a nurse or any staffer who's there? Like my, my sister is the Head of the emergency department at Royal Melbourne Hospital. And so I have some idea of her countenance, her, her natural state as a human is pretty laid back.

She's pretty chill. She's very no worries. Like it's gonna be okay. And that's, she carries that in her work. She's actually been featured on a reality TV show back in Australia. No one here will know, but I've seen her work and she's very calm. But I assumed watching her that that's very much like, oh, that's just, that must be what it takes to become a emergency medicine professional.

Do you have people turn up early days in the program, whether they're junior doctors or junior nurses and they want to run. Because they either think that that's what you're supposed to do, or that's their natural reaction, and you have to beat that out of them for, for a better word. 

[00:06:01] Dr. Al'ai Alvarez: Yeah. I think we're in a training facility, and so we see a lot of this earlier on. I think it, it, it manifests a lot better or, uh, to an extreme when we're in a resuscitation because either they're speaking faster, they're asking a lot of orders pretty quickly, or you just see them running towards the trauma bay when everybody's like just walking. And we do remind them. It's like, why?

Why are we running? What is going on? Oftentimes when I see running, like Sara was mentioning, I have to cue into is there a resuscitation that I'm missing? Was I not called to go into that room? Because oftentimes I do have a good handle either by just. Global listening to the entire department, the entire football field.

I think the more senior you become you, that's a skill that you develop to simply listen in the, the running, the, the commotion that's happening, similar to what Sara was mentioning earlier, of like going from one place to another. 

[00:06:53] Sara Marrello: You do have to tell people though, and I think that is part of like the cultural indoctrination in our community, is that you tell people, you know, jokingly the first time like, Hey, how are you gonna give orders if you're short of breath when you show up in this room, like, don't run. And then, you know, the next time you sit down and practically say like, you know, if you run, that kind of increases our operational tempo to a point where we may not be functional. So we need you to dial that back a little bit so that people don't get amped up with you. 

[00:07:20] Dr. Al'ai Alvarez: Interesting. And I actually had an example. So when I trained in the Bronx at Jacobi on the other hospital, Montefiore, we had to cover the block perimeter outside of the emergency department, which means that if there's somebody who passes out or has a seizure outside, like just in front of the lobby, we have to bring our equipment all the way to the other side of that hospital to pick up the patient and bring them back to the emergency department.

In my very early days. I was that person that would get begin. I mean, I mean, you go to emergency medicine as well because of the rush, the adrenaline thing that happens with, with all of this excitement. But then I realized that no matter how fast you run to those places, if you really are so short of breath, like I would, I would, I remember carrying the, the oxygen tank and they're not light. And so imagine running like half a mile and then you

[00:08:08] Paddy Steinfort: get there and, and, and just for anyone who isn't seeing a video and they're just listening, LA you're not a big man either. That's fair to say. I, 

[00:08:17] Dr. Al'ai Alvarez: I, I, I can normally run, but I don't run that far. And when I do with an oxygen with an oxygen tank and the adrenaline, right, you're in your mind, you're also thinking out loud like, what am I gonna get?

Because the notion of emergency medicine, we don't really know what's gonna arrive to us. Everybody arrives with a little bit of information, and we have to make critical decision based on those. And so in my mind, I'm already trying to figure out like what if they need X, Y, Z, and what resources do I have?

And the point of me sharing this is that by the time I get there, even though my mind is running pretty fast, I'm working to slow down my breathing because I, I cannot think, right? Like I'm blacking out. Literally, I'm like tunnel visioning because I'm, I'm out of breath. And so I think for me, that's when I first learned that there's no running in the emergency department. It's not like one of those TV shows where it's cool to run. It's actually not cool to run. 

[00:09:09] Paddy Steinfort: Yeah, because you also don't have a makeup department on the other side that'll touch you up before you step into the, before you step into the room. 

[00:09:17] Dr. Al'ai Alvarez: That's an interesting point. You don't even have to, to go into running into resuscitation just by being in a resuscitation. I think if you check out how we look after we leave that room, it's pretty funny sometimes because of the mask and the gown, we're really donning a lot of these, uh, protective equipments that you can't distinguish us from each other. And yet when we start peeling those out, we're just disheveled. 

[00:09:39] Paddy Steinfort: I can imagine. I can imagine the one part you that you mentioned there of that for most of our listeners who don't have to deal with, hey, we have to get to the next room, or that guy's gonna die on the daily, you know, so some of our listeners do deal with that, but maybe not every single day.

It's almost counterintuitive, right? Like every second counts would be a, a cliche throwaway. Like, if I get there in a second earlier, I might be able to stop, get there before he stops, or before she goes into respiratory arrest, whatever might happen. And, and so it's, it's that tension between, I, I want, I feel like I need to do this versus I know this is what's right.Can you talk me through that tension a little more or is that something that just resolves itself with reps? 

[00:10:24] Sara Marrello: Uh, no, I, for me at least personally, I feel like the pressure is always there. And I've been a nurse for a long time now, I think like 16, 17 years. And I can remember doing a resuscitation at a hospital that didn't have a pharmacist to help mix the drips. And we had just gotten the patient back. Their heart rate had returned. They were on a machine to help with their breathing. They were literally had died and just come back to life. And we were going to need to start these drips to support their blood pressure and their heart rate. All of these drips that were critical to keeping them alive as our rescue medications were wearing off.

I can remember standing there trying to mix the drips as quickly as I can. And I'm thinking to my, I'm actually physically saying it, come on Sara, you need to move faster. We need this drip right now. And, you know, trying to prime the lines down and get 'em on the pump and just kind of encourage myself to keep going because seconds do count and the people in those rooms are working as hard as they possibly can because when you go into this, you, you wanna save people, you wanna make a difference.

And so there is a lot of pressure going into those rooms from moment to moment. We count in, in seconds how long we are off the chest when we're doing chest compressions because we want to increase blood, you know, keep the blood flow as much as we can. Seconds count in this business for sure. 

[00:11:35] Dr. Al'ai Alvarez: Yeah, I think the corollary to that is that. It's very rare to really be in that situation. Oftentimes I can get 30 more seconds to just think and, and figure out what's happening, as opposed to, it's very rare for me to walk into a room and they're really dead or they're, they're dying. I usually have a, a buffer of, of thought process to do that.

And understanding when to do the thinking or when to just do the, okay, well, they're not breathing. Let's do chest compression. Let's do this. I think it's very key. And also understanding when to slow down when you're realizing that there's so much momentum that things are just happening so fast. Um, I mean, imagine Sara's, uh, she's explaining she has to do all these like critical drips.

Precision is, is, is very important. And yet you have somebody like me who may be nervous and will start rattling off like, I need a bicarb, I need a epinephrine. I need this. Like, Hey, what about the chest compression? And it derails the entire resuscitation because I cannot control myself. And so I think it's very important for me to understand that the, the 15 seconds may be 15 seconds slower if, if I can slow myself down versus the 15 seconds that I don't have.

And you just have to just dive in there. And, and sometimes I, as the attending might have to do chest compression because I can see that whoever's doing the chest compression is already very fatigue. And so I have to make co constant decision with,  I cannot touch the patient right now. I need to be the team leader and I have to be under the foot of the beds versus being hands-on.

And oftentimes cognitively, I'm actually distracting myself because I want to do everything all at once. And, and that's, I think, the tension, the biggest tension in any resuscitation. And Sara reminds us of that a lot, especially my residents, when they try to grab that bicarb or, or epi, have the medications that we, that we are trying to give.

And Sara will point out, it's like. I don't do your job, let me do my job. And then that way you can focus on doing your job. And she says it so nicely, that's not how she says it. She really says it so nicely that I was like, huh, that's a great perspective. Let me like put that in a, in a quarter later for our debrief, because right now I need to continue this resuscitation. But it's very little like simple communications like that that happen that I find it very, very effective for us. 

[00:13:53] Paddy Steinfort: Yeah, super interesting. And there's so much to dig into there. Firstly, from the element of, I can say 15 seconds now, but it'll cost my entire team minutes later if I ruin the team dynamic. But also in terms of that role specificity, I've been in, in a ER room as a observer a couple of times, oftentimes as a patient for orthopedic surgery, but I wasn't awake for those, for the watching. I, I saw an open heart, a few open heart surgeries, a couple, and it was fascinating to me to see the charge nurse.

Be almost the boss of the room when the surgeon walk. You know, the heart surgeon you would assume is the boss. He's the guy who gets all the glory and everyone points to him. But when the chest was open and when the patient, the blood pressure wouldn't come back on after they got off bypass. Like there was a significant shift in, the nurse took over and it was really interesting to an outside observer that there was that strong, clear, hey, this is what I do and this is my moment.

And there also wasn't too, you know, the surgeon wasn't butt hurt by that happening. I'm curious about, is that standard to all emergency teams or is that this is how a good team runs. 

[00:15:02] Sara Marrello: Yeah, the good teams. You know, what you said was like really resonated with me. You, if you have a leader in there that ruins the team dynamic, it will waste your time.

[00:15:13] Dr. Al'ai Alvarez: Yes. 

[00:15:13] Sara Marrello: And with Dr. Alvarez and I, now mind you, we work together in these situations relatively frequently. When I see him in a room and I see things kind of fluttering out of control, I will turn to him and be like, I'm gonna need you to take the reins, your boss, and there's this communication that happens kind of quietly, and I'm like, I need you to, to reel this back in.

And he has the little things that he does or he'll say, okay, we need to do a summary, or we need to highlight what the action items are for the team. I'm a great worker bee and I will get my job done. I like to swim in my lane. But when people start getting really frantic, I think what you said, making sure that that team dynamic holds together. And Dr. Alvarez is excellent at it. He really is. 

[00:15:55] Dr. Al'ai Alvarez: Thank you. Very cool. I think it's that the..

[00:15:57] Sara Marrello: Are you blushing? 

[00:15:59] Dr. Al'ai Alvarez: Well, well, no, no bushing, but, but I think it's very interesting because oftentimes there's not a lot of words that's being said. It could be a simple, Sara turns around because there's a lot of noise in the, in the background, and then she'll just look at me and says, Dr. Alvarez, that's it. There's no question there's, it's just like my name. That usually for me signals like I just need to make a decision for us to move forward because then I've already noticed if I am the attending for that room, I have a resident that that's being the team captain. Usually I have an idea of whether they're also either nervous or they're getting over.

Um, I, I'm trying to, to find a word, like they're just cognitively overloaded, right? And they, they're trying to slow them themselves down. One of the common things that happen is, especially when you're newer in the resuscitation, you want to also flex up to show everybody that you are in control. And often that manifests into your thinking out loud.

And from nursing perspective, what I've learned is that they're very task oriented. If you tell them to do something, they will do it, but they have to have priorities. And so one of the things, for instance, is when, when my resident thinks out loud, Sara will just look at me and say, Dr. Alvarez. And that signals to me like, you need to just take over because we can't be listening to 10 different orders all at once. It's like throwing everybody off, and we don't know the direction of our resuscitation right now. 

[00:17:19] Paddy Steinfort: Hmm. 

[00:17:20] Dr. Al'ai Alvarez: But I have to do very also like in a way that will still not devalue my resident because they are learning that team leadership skills. And so either I, I stand closer to them so that they know that like, I'm right there and then I start whispering, like asking them questions. Or if it's really out of control, I'll just say, start saying something. Okay, why don't we do this? Why don't we just step back? What have we done so far? And then that's when we kind of regroup again. 

[00:17:45] Paddy Steinfort: Very cool. Very cool examples. And I, I like the, uh, it seems like, I mean, if you're watching this, not many people will watch it. It's mostly an audio program, but you can already see the dynamic between the two of you where there's a pause and the other person steps in nicely. It's very, it's nice for me. It makes my job easier. Right now, one of the questions that we ask all of our guests is, what does toughness mean in your area?

Now, you've thrown out in that last little bit where we've described a couple of scenarios and you've talked about how to deal with 'em versus how a rookie might deal with 'em. You've mentioned a few what people might call cognitive skills and a few self-awareness skills, but let's just jump up to 50,000 feet for a second and look at the entirety of your jobs or, or of anyone who's involved in that ER department. What would you say makes a tough emergency medical professional, whether it's a nurse or a physician? What does toughness mean in your profession? 

[00:18:38] Dr. Al'ai Alvarez: So emergency medicine is being able to handle anyone anywhere, anytime. I think that's very true for our profession. People can just be dropped off and, and we'll resuscitate them if they're not breathing or, or there's some emergency that's going on. But toughness, I think is, and my chair under talks about this in terms of wellness, which is being able to go inside any room and have the capacity and the ability to manage whatever comes our way. I think toughness is being able to do that, being able to go into any room, not knowing what's happening, and then being able to, to take control.

And at the same time, I think being able to step back, be vulnerable later on, and share that's, you know what, I screwed this one up, or I could have done better with this one. I think that's harder than being able to just walk into a room, pretend that's, or at least fake it to everybody that's, I am getting control when in fact I have no idea.

And Sara had seen this with me. I, I will say like, Hmm, not no, no, no clue what's going on here. And here's what my thought process. And being able to say that, I think in, in a group of, let's say, trauma surgeons, my residents, their residents, the nursing team and the rest of the, the resuscitation team, and still feel comfortable to move forward without having to lose that connection. That's that I developed at the very beginning. I think that's tough. Yeah. 

[00:20:00] Paddy Steinfort: And so I'm gonna pull out a few of the threads there. Sure. That are removing the jargon and making them a little more general. One is the ability to deal with uncertainty or the unknown, to process data and information rapidly. And also to be v, to allow yourself to be vulnerable in that moment, which is an unusual element that, that I think generalizes, but that's a very specific one to what you just said there of saying, okay, maybe I don't know, and I'm okay to talk out loud about that because I need to stay connected. To the other people in the in the unit. Would there be anything you add to that, Sara? 

[00:20:35] Sara Marrello: So I thought about this when I got your email and I thought to myself, who are the toughest physicians and toughest nurses in our department? And what sort of qualities do they kind of share? And I was sort of surprised because there are a lot of physicians in our department who are very technically skilled.

Like if I needed a breathing tube or an IV or something, like I would go to them directly because they have great skills. But I didn't know that I necessarily thought they were the toughest ones in our department. I think some of the people who really pop to my mind the most, and something that's unique in emergency medicine is this ability to pivot from a very difficult situation to kind of a less high stake situation and still continue to show compassion for family A and for patient B.

That we have some doctors who I just don't. I am, and nurses as well, who just always have the time to sit down and listen. They don't compromise their care from one scenario to the next for 12 hour shifts, six days a week or five days a week. Some of our residents work insane schedules and they always managed to like dig deep into this well of compassion and still sit down and listen to each patient and take their scenario for, for what it is like as a standalone, which is really hard to do because in emergency medicine you can just get drained being in these tough situations and then be like, I need a break.

But there's no break. They're coming, they're here, they're waiting in the next room, and you need to go in there and not be dismissive of the second patient just because you used so much of your heart up on the first one. There have been moments in my career, I had a patient die and all of a sudden the charge nurse is like, okay, you're getting a new ambulance.

And I was like, whoa, do I, do I get a five minute breather? And I was like, okay, no I don't. So, hi, my name's Sara, I'm gonna be your nurse tonight. Big old smile on my face. And I was like, I don't know how I'm doing this, but this person deserves a smile and to be greeted and not just kind of thrown off.

And that is, I think part of emergency medicine that people, we don't give ourselves enough credit for is continuing to show heart to people, even on the 11th hour of a night shift where you've already done four or five critical resuscitations and now somebody comes in and they've got some belly pain and they're not really sure what it is.

[00:22:51] Paddy Steinfort: So, yeah, I mean, a great example there because we dove headfirst into the pressure moments at the start of this show. You know, the, the sexy stuff that's on tv. Oh yeah. But, but it's sometimes the long term, like, can I bounce back in two minutes and go to this other person and just be in the moment? Mm-hmm.

For that patient, or for this case, or for this room. Even though someone just died under my care five minutes ago, or even they may not have died, but I made a mistake that could cost me that next promotion or whatever it might be. How much does that long-term resilience, toughness, bounce back? I know LA that was probably one of the first things you and I spoke about when we first met years ago was the predictor of someone being a good resident and getting through and, and being a strong member of that team was how well can they deal with the long-term grind of this job. Is that a significant factor of toughness in your area? 

[00:23:44] Dr. Al'ai Alvarez: I've always thought for the longest time that I can screen out people based on that aspect, the way that they bounce back from one tough situation to another. And more and more I'm learning that it's a skill that you have to develop and, and they're very deliberate, as Sara was mentioning.

Being able to just take a moment after a resuscitation, realize where you are, checking in with your team, checking in with yourself, and then being able to just go to the next room and say, Hey, how are you doing today? I'm here to take care of you without having to bring all of that baggage from the other room. And to put it in perspective as well, that's, we cycle through this. Many, many times in the eight hours that I work in one shift. In one shift. 

[00:24:27] Paddy Steinfort: Yeah. 'cause a lot of the pro athletes that, that I, that I am blessed to work with, will deal with, I won't, I won't make light of the situation, but people act like someone's died after a bad loss.

[00:24:37] Dr. Al'ai Alvarez: Yeah. 

[00:24:38] Paddy Steinfort: And you know, there's almost a ceremony of it. You're almost, you're supposed to act sad and even if you've played well and the team hasn't, you Yeah. Everyone's gotta be down. And there's this whole, like you said before, Sara, a cultural indoctrination of this needs to be processed like a death or like something, you know, this is serious and we lost.

And yes, it is serious and there's millions of dollars on the line. Even the press plays along with it. And, and yet everyone gets 24 hours to reset sometimes, you know, at the very least before we go to practice again. But in football, you get a week and it's just, it's so different to being like what you just said.

[00:25:14] Paddy Steinfort: This happens multiple times within eight hours. 

[00:25:18] Dr. Al'ai Alvarez: 12 hours for Sara. 12 hours. 12 hours. Yeah. Well, I, I also wanna say that, and, and this is gonna sound very off for me. Oftentimes when there's a finality, a patient dies, for instance, we are more likely to be able to pause and reflect on ourselves and then be able to go to the next room versus the majority of our experiences is actually we resuscitate, we still have no idea what's happening. And then if they're so critical, they go to the operating room, they go somewhere else and there's no closure. And so there's a lot of these, like lack of closure that we have, but we have to stop this room and then go to the next room, and then, then we have to deal with whatever drama that's happening there.

Either they're upset, they've waited for so long, or they're upset because they're so worried. There's whatever else is going on with it. We have to give them that complete focus and then switch again to another room. And then that happens so many times in a given shift that. Sometimes it's actually easier to deal with a finality like the patient dies because then we can all be on the same page.

Like, okay, well we really did our best. We can share gratitude for each other. We can then debrief that part, and then we can move on. We rarely get to debrief the ones that we've resuscitated, but we have no idea what happened because there's just many more patients that we need to see next. 

[00:26:36] Paddy Steinfort: Interesting. So you mentioned there that there is an ability to learn these things. You, you thought initially that, that you had to have them, but as time has gone on, you, you think that they're trainable and learnable. We also play a game on here called Choke and Change, where we share a moment and experience sometimes during our career, during the Our story, our journey that we actually individually choked.

And it may, you know, it could have been earlier, it could have been a minor thing, but that our ability to handle that moment or not bou, you know, we didn't bounce back as well as we might've if it's a chronic stress thing. That we learned over time or we changed and we've handled that situation differently since, uh, Avira.

Have you got an example? You can, you can throw in there. Sara. Let, let me ask you a more direct question. Okay. What was the time at work where you didn't handle it early on as well as you do now? 

[00:27:27] Sara Marrello: So, I wrestle with my weaknesses on every shift, right? Like, I kind of know what they are. I can sometimes be very impatient with my coworkers. I sometimes will get frustrated when I feel like I know the direction we should go in and I can make recommendations. I can't write orders, I don't wanna be able to write orders, but I can make recommendations and sometimes people will be a little dismissive. So, the other night at work, and I'm, I'm, I'm thinking this will, this will apply nicely.

So the other night I'm at work and we have a patient who comes in who was in a traumatic accident, I mean, devastating, devastating injuries. And unfortunately the EMS crew that brought him in, he had passed away prior to arriving at the hospital and they were actively trying to bring him back to life. So he arrived and we have well-written protocols and we jumped into line and we were doing what we're doing and the physician who was in charge of the resuscitation ordered blood. And this patient had been down for a long time. And you're starting to think to yourself like, alright, I'm gonna hang this blood.

Are you sure you wanna hang this blood? You know, because I'm gonna start infusing it. And when I do like this, as soon as I open that bag, op up, it's done. And the physician was kinda like, yeah, yeah, yeah. Hang it. And I was like, are we sure we wanna hang this blood? Because if you're gonna call this in two seconds, then I'm gonna open this blood up and this blood is just gonna go to waste.

And again, a doctor just, no, no, no, you're fine. Just, you know, hang the, hang the blood, do it, do it, do it. So I literally open the bag of blood and I go to spike it so we can infuse it to the patient and they go, Hey, this patient's been down for a really long time. We've done all these different things. EMS tried to save them.

I, I, you know, unless anybody has any other ideas, then we're gonna go ahead and call this. And I was like, I needed to take a minute right. And center myself because my whole face starts turning red. And you know, we, we went through, we have like a whole ritual that we do when a patient passes away to pay respect to their life and the effort that we made.

And then I walked outta that room and Paddy, I was hot, I was so mad. I was star down the hallway. And Dr. Alvarez has alluded to these debriefs that we do, where we all get together as a team and we talk about what we could have done better and what we could have done worse. And I was walking down the hallway having a Sara debrief in her head where I was like, I can't believe how many people do I have to ask.

And then I'm gonna spike this blood and you're gonna call it before I even give the unit. Oh, I was so mad. And that's something that I wrestle with because sometimes I will argue with myself on the unit or I will drive home, still arguing with the physician, wake up arguing with the physician and come back to work and see that physician and be like, man, I have something I need to tell you.

But I feel like a growth thing for me is to make sure I do attend the debrief so that our physicians hold. And I find a diplomatic way to say, Hey, I just wanna remind you about how I asked you three times whether or not you wanted this blood before I opened it up. And I, you know, what upsets me is that somebody donated this blood, laid on a little stretcher for the Red Cross and got their cookies and they were hoping this was gonna go this way and you didn't gimme the opportunity to use this resource the way I wanted to.

And actually in that debrief, after I calmed down and talked to the physicians, they were very receptive and were like, okay, yeah, we didn't think about that that way. We were just thinking like, what we should do in this situation is give blood. Even though they also were thinking, Hey, we've already got a really long downtime.

I don't know that this patient's gonna make it. So that's definitely a moment where routinely I choke and then sometimes I pull myself out of it. Sometimes not so much 

[00:30:46] Paddy Steinfort: A great example, like so, so rich in detail there that like I can literally see that Yeah. Happening in my mind. I, I heard someone say the other day that talking is the toughest thing that people do.Mm-hmm. And that in this instance, your ability to have that conversation and have it in a measured way is really tough because you feel, like you said you are hot, you feel incredibly strongly about it. Mm-hmm. And you want to convey that. Yeah. As well as convey the information. But it is a skill to be able to moderate that, to be able to deliver the information without overloading it with excess emotional baggage so that the receiver does actually receive the message as opposed to get defensive or whatever.

You said it's something that you are working on. Is it something that you, that you've explicitly had training on, had coaching on? Has there been a. An intervention that has helped you with that, or is it just like you started to recognize it and I've, I've gotta get better at it? 

[00:31:39] Sara Marrello: Well, I have always had arguments with people when they weren't around, like, done that thing where you're like, we're gonna, I'm gonna talk about this all the way home.

But I really feel like Stanford, and especially Dr. Alvarez, who is someone who really believes in the power of a debrief after anything, after a success, after a failure, after a mediocre, you know, attempt. I feel like the program that we have at Stanford and these physician left debriefs, where they literally look at every person from the respiratory therapist to the patient care technician, to the resident, to anybody that we can get there and say, how did that go for you and what worked for you?

That kind of leadership, that's something that started at Stanford that I've learned at Stanford. And when Dr. Alvarez isn't there, I will drag people to the debrief and say, this is important for the team. You need to do this. Otherwise people are gonna walk out of here and still. Be thinking about this and it helps provide that closure. I think it's, it's essential to any success or failure to In order for getting better at what you do. 

[00:32:37] Paddy Steinfort: Yeah. Both individually and, and at the team level as you mentioned it. 

[00:32:40] Sara Marrello: Yeah. 

[00:32:41] Paddy Steinfort: Yeah. Absolutely. Yeah. LA you, I never did that. Any other examples? 

[00:32:45] Dr. Al'ai Alvarez: Well, I love to actually tag with that example that Sara shared because I was not always that person. In fact, one of my toughest moments in my career is because I was that person who would ask for that blood, because in my mind I'm always doing quick calculations, risk benefits, but then not having the long-term effects or not having thought about the other social aspects of the decision. It's more of.

I need to get this patient alive and maybe the bud will help. Maybe this will help. I used to not think of the cost, I used to not think of the labor that comes to that, or the process that it takes for me to actually do the, the task that I'm asking for. And so earlier in my, in my career, I struggle with that a lot.

In fact, if, if there's one thing in my early career that I can change, it's this ability to just, you know what, let's step back. Why don't we just talk about what happened? Because in a different perspective of what Sara just shared, I was that physician who would be I asking so many things. I would like pace because I'm asking for things.

I want things to happen so quickly because in my mind it has to happen stat. It has to happen immediately. Then I realized nobody dies if I give them 15 more seconds. Nobody dies if, if the nurse just has to take one more time to actually double check the medication. But me rushing me expecting, like just give it, undervalues them, it also prevents them from actually doing their task in their mind because they have a, a system that I'm trying to negate because in my mind, just do it.

Just give it, and that attitude has caused me a lot of trouble earlier on. And it took me a lot of years to actually overcome. And you asked like, did I get any specific training? For instance, one of the things that I've learned lately in the past several years was the idea of self-compassion. Because a lot of it boiled down to I was not sure and I was not comfortable being vulnerable with people.

And so I needed to fake it because I was working in a very busy place and I need to prove to everybody that I'm just as good, if not better than every everybody else that they've worked with. Versus now I've learned to say, I have no idea. Or I've learned to say, Ooh, not sure about this one. Anybody have any thoughts on this? And especially after the resuscitation and say like, that didn't go so well. Ooh. Or simply like, Hey, what do you guys think of that? Why don't we talk about it? I find it very interesting that Sara calls it physician led debrief, because I've always learned it from the nurses. In fact, the nurses are usually very good with reminding us, Hey, that was a tough case.

Can we talk about that? And it's that subtle thing that they ask us, and yet we're leading it. But really, it's usually nursing driven when a big resuscitation happens. And now I try to use that as a template for any source of resuscitation, whether it's good or bad, just to, it gives me a time to also acknowledge people, to remember to respect each other's roles, and also to just share with them that I am also willing to change and that I, there are areas here that I could have done better. And for me, when I started doing that, I remember this clearly. I think Sara was there. One of the techs started saying like, oh, that was on me. I could have done this better. And then somebody else started saying like, oh yeah, I think this could have been better without me actually telling, pointing fingers like, you screwed up on this.

You screwed up on that. People start like, when I think when I share my vulnerability, people. Tend to share theirs as well. And for me, those teams are very precious. Sara and I work nights only, and so we are more familiar with each other's work, as opposed to if you put me on a day shift, I have no idea who I'm gonna be working. It's a lot more variations of the staff and I cannot always do the debrief that I am so used to doing in the middle of the night. 

[00:36:31] Paddy Steinfort: A really, really cool example from both of you that overlaps there, the, the things that, you know, if, if I was to cherry pick or, or try and coalesce that was, and, and it does line up with a lot of the broader work on dealing with the psychological elements of these sorts of jobs, is that there are three parts to, to what we're dealing with.

One is to be able to deal with reality as it is, which includes being vulnerable. And if I don't feel good, it's not about feeling good. I have to, in order to do what we need to do, I need to accept all of the elements of the experience. Two is to stay focused in the moment on. Here's what we're trying to do, and just at this moment, whether it's have a conversation or whether it's dealing with the issues around a patient, and three is all towards what end.

Like we're all trying to achieve a certain goal or this thing, we're trying to move towards this thing that we value and that in different contexts and in different roles, they present as different skills to a degree, but that it all eventually comes back to that and, and that it's, that it, it broadens that definition of toughness to a degree where it's not all about, Hey, I'm just gonna yell, or I'm just gonna get this job done.

It's sometimes about being vulnerable and opening up and being flexible, which is a little bit counterintuitive in some ways. You've both mentioned there your learning experiences and how other individuals have influenced you along the way. Are there any particular, I I, I steal this bit from a guy called John Gordon, who is a bestselling author, also a speaker at, at some of the teams that I've worked with.

And when I met him, he was just introducing this exercise that he called Hero Hardship and highlight, which is a way to be vulnerable within a team where you would get one player at the front, they'd sit on a stool and they would share something from their lives that was under one of those categories.

[00:38:23] Paddy Steinfort: We've spoken a little bit about the hardships already. Uh, I'm interested if you want to explore, either of, you can take this with either a hero or a highlight that talks about some of the individuals or some of the positive side of your work. The hero is usually who has impacted you along your journey, who has inspired you, who has forced, you know, moved you to, to change things in a positive way or the highlight is, Hey, here's actually something that we don't talk about enough. 'cause it may not be as sexy as though we resuscitated that patient, but it is really. One of the best parts of being in this kind of a role? In this critical role? 

[00:38:59] Dr. Al'ai Alvarez: Yeah. I love my job. I love being able to walk into our emergency departments, and Sara was mentioning earlier, the waiting room is 45 patients needing to be seen. All of that for me is a challenge because at the end of the day, I'm going home right after eight hours, I'm gonna do my best, I'm gonna go home. I think the highlight for me is being able to take care of all of that. The key for me is being able to take care of all of those patients and finding a moment to simply debrief.

It's not necessarily the saves or the losses or the deaths, it's the relationship that I get to continue to have. One of the best things about working in nights is because I get to work with mostly the same people over a long period of time, and what that manifests for me is that I get to see myself grow and develop, and I also get to see my residents grow and develop.

: In this environment where the nurses are also watching us grow and develop, we don't always get to say that. We always get to focus on the beginning when people are a little bit greener, they're definitely very green to when they graduate and they're able to resuscitate. For me, the highlight is finding those moments on every shift to just acknowledge them and to kinda create milestones.

Hey, I just wanna let you know that you just did this. Or even finding that time to, or space to say like, Hey, what you just, what we're talking about here, I want you to just remember what this feels because you just saved a life and you will not always get to remember this because you'll always remember all the patient that dies or all the, the tough parts about our job.

But being able to say like, Hey, and again, Sara, I can, I, I have vivid examples of cases in my heads of those resuscitations like thoracotomies and really like tough resuscitations, and being able to go back to the resident who's leading that, who's very tough on themselves, oh, I could have done this. I could have done that.

And simply walk down the hallway and say like, Hey, I just want you to remember that this very moment. This is how it feels like to save a life. This is how it feels like to do a great job because nobody reminds you of that. It's always like at the very end, at the very beginning and not during the, the many examples of these cases for them.

[00:41:17] Sara Marrello: I can remember resuscitation we did with Dr. Alvarez and we debriefed it and this guy had come in, he had been shot multiple times in the chest. He came into the emergency room, died. We brought him back to life. We intubated him, we put all these tubes in, we sent him up to the or. And in the debrief, this resident who's adorable, he is like, I just, I feel like we were disordered, blah, blah, blah.

And I had to stop him. And I was like, dude, we did all of that in 20 minutes. That whole experience, everything was 20 minutes door to the or. This is the highest level of medicine that you are practicing right now. Like you can wanna nitpick that apart, but at the same time, like that was amazing. You know?

Like, yeah, it was an airway. I know you, I wonder if you even remember, but it I do. Yeah. They like the practicing LE medicine at that level is so exciting. Pulling a team together and saving people's lives and doing it so efficiently. And I, I think for our residents, it's a growth thing for them to be like, you can sometimes win.

You can sometimes be really good at your job. And when you go to these debriefs and you tell them, Joshua Stein, that was one of the best resuscitations I've ever seen. I know your only second year emergency medicine, but you stayed calm. You were measured. And he's like, really? And we're like, yes. 

[00:42:33] Dr. Al'ai Alvarez: Yeah. 

[00:42:34] Sara Marrello: Do it like that every time. Yeah. It's so great. Very exciting. 

[00:42:36] Dr. Al'ai Alvarez: Their measurements, which is so weird for me, and I never really understood this. The bar that I had when I was training is so different than the bar that I have now. And yet it doesn't change the way I take care of my patients. It simply changed the way that I see myself, my, the way that I take care of my team.

And it, I think it boils down to just finding moments of [00:43:00] celebrating little successes, finding moments of really pushing somebody to, to do better without making them feel like you're crap or you're screwed up on this. And, and for me that was very hard to really learn to do. And I saw that throughout my experience at Stanford. I think it's just seeing other people delivering that. It's like micro moments of just celebrations. Yeah. 

[00:43:21] Paddy Steinfort: Yeah. I had a great coach that I worked with back in Australia before I left for the US who used to say, you'll get 10 kicks in the ass for one pat on the back in this business. And so you don't wanna miss the pats. And, and he actually described his job, which was probably a little similar to your role of keeping the balance. When the team felt good, he needed to make sure that he didn't let everyone get too high. When the team felt bad, he needed to remind them like, Hey, there's some good shit going on here.

Don't, let's not lose the forest for the trees. Great example there. And that, and I'm, I'm using that kind of partly to relate it to my own field, but also because a lot of this show is to share some of our very specific and unique experiences in very unusual context with people who don't do these jobs but still have to deal with, I'm having a conversation with my partner that could derail the relationship I'm trying to present to a venture capital firm and get funding for this business that I've always wanted to start.

I'm trying to present for a promotion. I'm auditioning for a job, I'm dealing with a critical situation at work. It could dictate my future. There's all sorts of high pressure moments or setbacks as well that all of us face as humans. That a lot of these skills are transferable to, what would you say in your respective roles, or let's just say in emergency medicine in general, that you would look at it as, here's a skill that is very applicable in our world, but it also is actually transferable to other areas of my life. I've seen that when I've got better at this, it's helped me get better outside of work. 

[00:44:54] Sara Marrello: So I think if you were to say, Hey Sara, I want you to talk to this NFL player who is gonna lose a game and lose a ton of money, and I need you to encourage him as a high performer or a stock person, any of these people who are in these high performance environments and say, what advice would you give them as somebody who's a high performer in your field?

I would say, number one, you need to take the losses and sort of leave them where you are because this ability to pivot and move on to the next thing, like you can't give your full atta attention to patient B if you are still figuring out what you should have done with patient a. And I don't think a football player can do as well in his next game if he is still losing that game over and over. In his mind. You have to, 

[00:45:33] Paddy Steinfort: or even in in that example, sorry, to, to shrink it a little bit is you can't give your full attention to play B. Yeah. If you're still on play A within that three hours of a game or, or if you're in the military, you can't give your full attention to maneuver B if you're still on maneuver A.

[00:45:49] Sara Marrello: Yeah. No, I mean, our ability to turn from one patient to another is something that we work on, and we have to kind of reset ourselves and find a way to do that, and that would be a big piece of advice I would give to them as well. And then also to cycle back to what we were just talking about, high performance people, I think, have a tendency to wanna pick everything apart and find the failure in it sometimes.

If you wanna love your job and keep loving what you're doing, which I still do after all of these years as a nurse, I still love being a nurse. It's because sometimes I just go, that was exciting and awesome, and I just let myself be happy with what I did. And I'm sure if I wanted to get better, I could sit down and find something I could have done differently.

But sometimes I just wanna be like, I'm gonna take that as a win and I'm gonna move on because it makes me love my job. I wanna be good at it. I don't always wanna find what I did wrong. Sometimes I just wanna be good and keep going. So those would be my two pieces of advice to other high performance people.

[00:46:44] Paddy Steinfort: Interesting. So, and that second one was very specific. The first one was a little, it's very good advice, but what, what's your actual technique for doing that? Like, I had, we had a comedian on this show recently who said, you know, ignore the haters is an Instagram quote. Like, how the fuck do you do that when there's actually haters trolling you on Instagram?

And so we, I, I want to dig down to when you say, I need to be able to leave that loss behind, or I need to be able to leave that bad incident behind and move to the next one. What's your trick for doing that? How do you do that? 

[00:47:13] Sara Marrello: I don't know. Like, how do you keep going in any situation where something falls apart, you just, do you? For me, it's literally, I can remember that moment I described earlier when I had to turn for my coding patient to my new ambulance, and it was a deep breath. Put the smile on your face. We're gonna fake it till we make it, and then we're just gonna turn and we're gonna keep going. It's one foot in front of the other.

[00:47:31] Sara Marrello: But I, I do think you can sometimes have this like physical reset where you're like, okay, that's done. Okay, hi, I'm gonna, you know, what can I do for you today? And it just has to be a pause and restart. You have to be very careful not to drag it with you, but the way that you do that is by literally being like, this is over starting new, you know?

And so year old PlayStation where you hit the button and you're like, okay, that whole game sucked. We're just gonna turn this whole machine off and restart it again. 

[00:47:56] Paddy Steinfort: We're back at three. 

[00:47:57] Sara Marrello: Three lives, everything's gonna be fine. 

[00:47:59] Paddy Steinfort: I know some people who would rip it out of the wall and throw it away, but that's a different, we should talk about that. Different approach, probably. Yeah, exactly. Not as effective. 

[00:48:06] Dr. Al'ai Alvarez: I think we've seen that sometimes in a resuscitation when somebody gets really, really angry and they dispel all of those emotions immediately. I. I think to follow Sara's example, I do the same. I've learned a lot about box breathing lately. I've learned a lot about slowing my breathing. Uh, Sara, so can you share that specific for those who aren't familiar? What's box breathing? Yeah, I think the military calls it either box breathing or tactical breathing, which is taking, and there's several versions of this. I do the taking a deep breath over four seconds and then holding your breath for four seconds and then exhaling over four seconds.

I feel calmer already just from you, and then holding your breath again over four seconds. And Sara has heard me say this to my residents as I'm teaching them how to do a procedure and they're shaking and I need them to be precise with where that needle is going to aim. The tone of my voice [00:49:00] will do the same thing. Sara has also heard me at the very beginning of a resuscitation where I'm very hyped up because I'm excited about what's coming. So then I realize like crap, like the adrenaline has surge so fast that I need to slow myself down. So you'll hear the, the way that I'm talking right now, the way that I'm slowing the cadence of my speech has been very helpful in resuscitation environment because then if I slow myself down, I realize that people are going to try to listen because I've established at the very beginning my role, Hey, I'm the team leader.

And so if I'm saying something they cannot hear, they're trying to like turn around and listen to me more, as opposed to I am screaming and raising my voice and it revs up everybody and then it's chaos. And so when I notice that, for me, a very tangible thing is to slow down my breathing, slow down the way that I talk, and I share this during the debrief, I'll share that.

I'll give them specific example. I don't know if you guys saw this, but when I was holding that C collar, my hand was shaking and then people start to remember. And then I'll say, and I don't know if you remember this, but I started slowing down the way that I speak and then people started like listening and started hearing what I was saying.

And usually that way of modeling can be effective with resin. Not always, but the ones that are truly, they, they want to get better are the ones that are tougher on themselves. They'll realize that, that it's a simple intervention that they can do, and I, I do that whenever I give a lecture in front of a, a big group.

I do that like when I'm taking a test, for instance, and it's not something that I've done a lot in the past. I think that's, that mindfulness aspect of it is very, very important as Sara was mentioning, because it allows me to then hear my thoughts. It allows me to then focus myself and be able to then realize like, Ooh, that did not feel well, or, I'm really getting revved up right now. And then it allows me to say. Again, in, in, in the emergency department, it's, people think it's always an emergency when it's not. You get burst of emergencies. And so you can always find moments to then just walk like just a lap around the ed. Uh, or even like, if you don't wanna walk all the way around the football field, you can just walk from one side to the other, like, I don't know, like five rooms.

But in those moments, for me, that's been very helpful in slowing myself down. Specific example that I've shared, for instance, is giving a sandwich to a patient. And it doesn't have to be really fancy, but in my mind, I'm very deliberate about it. I'm gonna walk that two minutes to go to the refrigerator and pick up that sandwich, and I'm already slowing my breathing and I'm gonna give it to some random patient who I know will be very grateful because who wouldn't want a sandwich?

Right? And then I'm just gonna give it to them. They're gonna thank me. I'm gonna thank them and I'm gonna go to the next room. See that next patient. Hey, I'm Dr. Alvarez. I'm so glad you're here today. They will never know that I just actually resuscitate a patient that died. And, and sometimes I show my, my, my, my resident stats or, or even when we give those tough conversations with a patient's family that their loved one just died, I'll be the one that will say, Hey, can I get you a cup of water?

Or do you want coffee? Right? We can delegate these. There's simple things that we can easily delegate, but for me, I would take that on and it allows me to recenter myself. 

[00:52:36] Paddy Steinfort: Really, really, really, really, really cool examples there from both of you and, and very practical actionable strategies. One being the breathing or the physiological intervention of I'm gonna do this thing, which forces me to slow down and actually turns down some of my hormonal and adrenal responses to this sort of chaos. And secondly, the full engagement in the next task. Whether it be task relevant, like you said, Sara, to turn to the next family and smile. And here's what I need. Here's the things that I need to do to be able to deliver in this next play. And I can't keep dragging the past. Play with me if I'm fully, if my mind is fully focused on this next one, four or five different things.

Smile. Give a greeting. Find out what's going on, whatever. Whether that's a task, relevant example, or it could be disengaged for a sec, distracts for a sec, go and get a sandwich for a patient. A little less task relevant in terms of saving lives, but it can be just as effective in absorbing yourself in a, in another task, in another activity. It allows you to build that buffer and move into the next one being fully engaged. Fantastic examples there. 

[00:53:43] Dr. Al'ai Alvarez: I do wanna say as well though, that, that for me is temporary, right? I just, I, I don't want to take lightly with the fact that I just resuscitated, my patient just died and I'm quickly switching so that I can put on this face for the next patient. I have to still deal with that. I think in order for me to move on later on, usually, like Sara's saying, like those ruminations happen when I drive home. That's why I deliberately picked a place that's an hour away, 45 minutes away from, from the hospital because I want that drive because it calms me down and I can think about it.

And I think during that drive, I have to acknowledge that I've also done something really incredible here. Because it's not always the losses. There's always the, again, I remember the staff members that I get to interact with the highlights that we were talking about earlier and putting that into action.

I write a thank you note, like, uh, and they say that there's, there's three positives that's needed for one negative. And so you'll see me usually on a very tough shift. I'll write thank you notes, I'll send like emails to the supervisors. I just wanna take this time to, to acknowledge X, Y, Z, because I think that letter of gratitude really helps me put perspective into what I could not control, right?

There's no way that I could have saved that particular patient, for instance. But I have the ability to thank people still, right? No matter how tough a day has been for me. And that for me also creates that connection, that continued connection that is needed because. As Sara was mentioning, we're back the next night.

We have to show up again. And so I don't wanna dwell on the negative things that happened, or even if it's a positive thing, again, I'm banking. If it's a positive, definitely I'm gonna like ride that wave. I'm gonna like milk that like as much as I can to then remember that we don't always talk about the negatives because we get those emails, we get those emails about like, secure emails.

Can you tell me about this patient that died? Or Can you explain to me your thought process? And so those are a lot of negative triggering things that happen in, in our day-to-day life outside of our clinical work. And so for me, I think something very simple is simply writing down a thank you letter or acknowledging them.

[00:55:47] Paddy Steinfort: Very cool, very cool examples that are transferable to all of us in our different arenas in life. Again, so thankful on the topic of gratitude that both of you have been able to join us, especially Sara, dealing with the, uh, lack of sleep and coming straight off a shift. I wanna wrap the show up with anything that, that you've got in mind in terms of when you think about.

These aspects of your job, and some of them are more commonplace than others, but they're, they're, as you said, you've become more aware of them. As you've gone on in your career, the importance of mental toughness, of being present, of being able to handle those stressful situations, what's your hope for the future for a young future?

Sara Morello, who joins the nursing profession straight out of school, or for a young Dr. Alvarez who rolls up to Stanford Emergency as a resident and is there to conquer the world? Like what? What are you hoping that the future of your industry holds? For these sorts of skills. 

[00:56:40] Sara Marrello: So I would say I've precepted new grads before and I, I've, I've taken care of younger nurses as they get started on this. I think what I would tell even my younger self would be, we do this for a reason. Um, for me it's because I love people. I love people and I love exciting medicine. And that you need to lean into that as much as you can. It's very hard. And there are parts of the culture of healthcare that will tell you that it's better to be angry or it's better to be cynical or that we're just being taken advantage of.

And I just throw all that out the window. I do this for the patients who tell me that I made a difference in their stay. They were glad I was here when you walked into the room, I knew you were gonna take care of me. And those are the things that I hang onto the most. And then I just try and let the rest go.

And then always remembering and sharing those exciting moments where we do something remarkable. 'cause we do remarkable stuff all the time. And it's worth sharing. It's worth crowing from the rooftops when you have these exciting resuscitations. And if they can always turn back to those two things, the exciting medicine and the compassionate care of these patients, they will get to be at the bedside as long as they want to. And that's what they should really focus on to have a a long career. 

[00:57:48] Dr. Al'ai Alvarez: Great  example. Love that. I'm gonna double down on compassion and specifically in self-compassion. I think that if I learn something, especially in the last decades of being an attending emergency medicine, it's the fact that there's so many things that I have no control. And yet at the same time, I can be kind to myself when things don't go so well because I. Oftentimes what I'm seeing when people are rude to each other, it's because they're either not nice to themselves or they're trying to hide from a lot of their shame or or whatever else issues that's running in their head.

And I think if we can recognize that we're all just humans, right? There's a common humanity here that they're also struggling or just like me, they're not having great days all the time. I think that I would've seen emergency medicine in a different lights earlier on. I think that's why I love emergency medicine now much better, because when people are struggling, I can see just like me, they're just trying their best.

They're just trying to prove to everybody that they know what they're doing. And if I can reassure them that, if I can say like, Hey, low stakes here, don't worry. You're gonna try. And if not, I'm right here and I'm here to guide you and. If I had known that safety, that I can be still kind to others because if something happens, like it's not just on me, then I think healthcare will be so much better.

I think we would take care of each other more. We're taking care of ourselves better, and in the end, we're not gonna be practicing with, especially in the US with very expensive medicine because we're trying to cover ourselves all the time.

[00:59:21] Paddy Steinfort: Really, really interesting point there. The last similar question, but would be a bit on the topic of what you just said there, Sara. What would your advice be to a young person who's starting out not in your field? So that was, that was some ver fairly specific. So you would say maybe the same advice, but to someone who is trying to make their way in the arts or in sport or in first responders, fire department, police in the military, what would your advice be to them in terms of handling stressful situations? Because you do it on the daily, 

[00:59:51] Sara Marrello: I would say, to always remember why they're doing what they're doing. You picked this for a reason, whatever it was, and in the difficult times, just lean into that. Like if you decided that you were wanted to be so like a pro football player or a pro athlete or something like that, they had to do that for a reason.

Maybe it was because they loved how powerful their body felt, or they loved that moment when something got executed perfectly, then just lean into that because there's gonna always be disappointments. Nobody's gonna win all of the games. Nobody's always gonna make the perfect deal. Nobody's you're going to fail.

That's just life. But if you just remember those moments when it was done really well, that's something to get excited about in the long term. It'll keep you going. It can keep you going for a long time, 

[01:00:35] Dr. Al'ai Alvarez: and I think that's, if they don't go so well, perspective is very, very helpful. In five years, will it really matter? In five minutes? In five hours, in five days? Or an eight, whatever number, pick something. But I think creating perspective over time has helped me a lot when I failed on certain things, when I missed a deadline or when a resuscitation did not go so well. I think being able to understand that there's only so much that I am able to do that being able to also understand that, you know what?

The movies in my head right now is very, very critical, and yet in five weeks, five months, I won't even talk about this. This will not even be as relevant, and that for me gives me the ability to focus on the why of why I'm doing things, being able to understand my own motivations as well. Being content with what I have. Sara mentioned earlier we're, we're extra tough on ourselves, especially in high performance teams and being able to, I think, dial that back down a little bit is also very important. 

[01:01:36] Paddy Steinfort: Very, very, very solid and salient examples there. And I appreciate both of you. As I said before, for for your time and for sharing and opening up being vulnerable in this way. Normally at this stage of the show, we'll ask 'cause some of the people are performers or promoting a book or whatever. I assume neither of you are promoting a book 'cause I haven't heard about it. Is there anything that, that you want us to provide to I'm not in our emergency room either. 

[01:01:58] Sara Marrello: You don't have to come if you don't need to. Exactly. So, so if people this, but don't feel obligated to come to Stanford. Yes. 

[01:02:07] Paddy Steinfort: If people wanted to find you and, and talk further about anything you've shared, they would go to Stanford Emergency Department, not in person, but they would contact you there. Is that correct? Yes. 

[01:02:18] Sara Marrello: We'll be there tonight and in fact, yeah.

[01:02:22] Paddy Steinfort: Great. Well, I appreciate your time and, and thanks again for sharing. Uh, it's been a really interesting chat. Good luck at the shift tonight. Hopefully you get some more sleep. Sara and Dr. Alvarez, look forward to talking to you soon. Of course. Thank you. Thank you.