That goddamn vessel ripped again. I was getting increasingly frustrated. I could feel the tension in the room, the eye-rolling in the anaesthesia booth. Everybody wanted this to be over, including me. But we couldn’t stop. That microsurgical anastomosis had to be done, otherwise the flap would be dead, and the patient depended on it.
Sure, the neoadjuvant chemotherapy and radiation therapy the patient had received after a severe cancer diagnosis didn’t help with tissue viability. It felt like suturing butter. But that wasn’t the patient’s fault, and it was my problem to deal with.
And then I saw the face of my nurse and I remembered my personal micro-reset protocol that had helped me countless times before, developed in a situation just like this one.
I put down the micro-instruments, detached from the microscope and closed my eyes. I took one really deep breath in through the nose, held it, and released through the mouth. Already there I could notice how tense I had inadvertently become, now that my muscles relaxed.
I then reminded myself that I had solved tricky cases before, and fully surrendered to the situation at hand. I literally stopped fighting it.
The next anastomosis was still sweat-inducing, I switched technique and it held. The flap came alive, we wrapped up, and it was fine.
Without that micro-reset, I might have continued to push through it the same unsuccessful way for another two hours.
That is not to say that I haven’t lost flaps in my career. Every surgeon has a graveyard, so to speak.
But here is what those years taught me: the fastest way to lose two hours in a high-stakes environment is to spend ten seconds not stopping.
Sounds backwards, but it’s not. You can see the ten seconds you lose. You cannot see the two hours you save. The mistake that didn’t happen, the conversation that didn’t escalate, the work that stayed clean instead of compounding an error because you kept gripping.
And there is a second reason: ten seconds of deliberate stillness, under pressure, feels exactly like the thing high performers have spent their careers avoiding.
Because most high performers are married to momentum.
Your pressure valve
But once things don’t go as planned, we tend to tense up and push through. And when that doesn’t yield success, we tense up even more and get stuck. This typically can’t be solved with more pressure. To the contrary, you need to find a way to release that pressure, so you can think clearly again.
Unfortunately, there has been a tradition in surgery of releasing pressure by taking it out on others. Screaming, yelling, bullying, kicking, throwing instruments, you name it.
And the same way we learn grieving from watching those around us, from the dramatic throwing yourself on the ground to the stone-faced silent intake, we learn to release pressure by watching those around us.
I believe that is something that has to be reflected upon consciously. You have to watch yourself and see whether the strategy you have adopted is a) serving yourself and b) not harming others.
This is where practices like yoga and breathwork come in handy. To be clear: what I’m describing here is not mindfulness. Mindfulness is the daily practice that makes these ten seconds available when you need them. The reset itself is something narrower, a mechanical intervention.
Of course you can decide that every time you feel the pressure rising inside of yourself, you go running or hit the gym. Which is great. Just not something you can do in an OR, or any other high-stakes environment, for that matter.
Why breath?
Breathing is the only one of your autonomic body functions under direct voluntary control, and it is directly wired into both your sympathetic fight-or-flight system and your parasympathetic rest-and-digest axis.
That means you can learn to influence and alter the state of your autonomic nervous system. Something professional athletes have known and used for a long time.
And the good thing is, it doesn’t take much. A few conscious, long, deep inhales and exhales go a long way. If you take one thing: make the exhale longer than the inhale. The exhale is when your parasympathetic system takes over.
Your mental interference
That is the physiological component. And then there is also the logic component.
Because the reason the tension and pressure build up in the first place is a Buddhist truth: your frustration stems from the difference between your expectation and reality.
The gap between how you want things to go and how they are actually going.
In my case it was the reality of the fragile tissue colliding with my wish that it would just behave as normal.
And the more we focus on what we want, on how it should be, the less perceptive we are to what is right in front of us.
Once we let that expectation go, through the micro-reset breathing for example, we are able to see reality as it is. And from there we can adjust our next move, which often then brings the result we had so desperately been focusing on before.
The hard part
Now all of this sounds fine. The challenge is not so much in the doing. The breathing and letting-go part is not particularly hard.
The challenge is remembering it when you actually need it. Because in the moment, stopping feels like the failure, and pushing through feels like the discipline. It’s the other way around.
What I tend to do when trying to learn or implement something new is set reminders through the day for exactly this.
Then run it when nothing is on the line. Do it twenty times in low-stakes moments. The twentieth rep is the one that shows up when everything is.
Also, when coming out of high-stakes situations where you haven’t done it, reflect on what happened and how it could have helped. A sort of personal debriefing moment.
And lastly, talk to people about it. I told my nurses, asking them to remind me when I get tense, or when they feel the situation is tense, to take a micro-break. Doesn’t mean they are always aware, but the more people are in the loop, the higher the chance of it actually happening.
Since we briefly touched on culture, there is another component to it. The notion that you might look weak and indecisive when pausing. In my experience, the opposite happens: the calmest person in the room, the one with poise, is the one everyone turns to.
The actual protocol
What I did at the microscope that day was the instinctive version. Over the years it has distilled into something you can actually install:
Seconds 0–2: Hands down.
Whatever you’re doing, stop doing it. The physical stop comes first.
Seconds 2–5: One long exhale.
Not an inhale first. A slow, deliberate exhale is the fastest available switch from sympathetic to parasympathetic tone. Do it longer than feels natural.
Seconds 5–8: Eyes wide, middle distance.
Stress narrows the visual field. Soften your focus, let the peripheral vision come back.
Seconds 8–10: One internal sentence.
Not a mantra. One sentence that names where you are: I am in this case, at this step, and the next move is X.
Ten seconds. Then you resume.
As always: take what you like, adapt it to your life, and hopefully create a way to navigate high-stakes, high-pressure situations better in the future.
To more from life
Nicco
