The First Ninety Seconds: How Clinical and Military Leaders Make Decisions Under Pressure

The first ninety seconds of a crisis tell you almost everything about a leader. You learn how they think, how they prioritize, and whether they are capable of holding the center while everyone else around them is losing theirs. The instinct to freeze, react emotionally, or overreact is natural. The ability to stay calm, deliberate, and composed is not. It is learned. It is practiced. It is earned through experience and exposure to pressure.

I learned this early in my career as a nurse in busy emergency departments and carried it forward through military commands, high-stakes federal leadership roles, and large health system responsibilities. I have watched leaders who could walk into chaos and immediately bring clarity. I have watched others add confusion because they lacked the internal stability to match the external environment. Those first ninety seconds matter because they set the tone for everything that follows. They decide how teams respond, whether communication remains orderly, and whether the mission stays intact.

Two experiences from my career illustrate what real composure looks like. One happened on one of the darkest days in American history. The other happened in a war zone during a mass casualty event. Both shaped how I teach leaders to navigate crisis today.

A Commander’s Calm on 9/11

On September 11th, 2001, I was assigned to the White House Medical Unit. That morning, President George W. Bush was visiting an elementary school in Florida when his Chief of Staff, Andy Card, quietly leaned in and told him that the country was under attack.

Many people remember the video clip. Most remember the look on the President’s face. What most miss is the leadership lesson embedded in those thirty seconds after he received the news. There was no visible panic. No sudden rush to stand. No barked orders. No attempt to project strength through theatrics. Instead, he showed a level of internal steadiness that communicated one thing to every adult in that room and every child watching him.

Stay calm. Stay present. Stay in control.

He finished the moment he was in. He let the gravity of the situation register without allowing it to dictate an emotional response. He modeled composure. And in doing so, he bought the team around him the psychological space to begin making their own decisions with clarity rather than fear.

This is what most leaders underestimate. In a crisis, teams look first not for direction, but for emotional stability. They want to see whether the person in charge can absorb the shock without transmitting it. The President’s calm that morning allowed the rest of the leadership apparatus to activate without panic. That calm was not weakness. It was discipline.

Healthcare leaders can learn from that moment. Every crisis begins with people looking to you to decide how to feel. If you lose control of yourself, you lose control of the team. When you hold steady, you anchor everyone else.

The Trauma Czar in a War Zone

Years later, in Afghanistan, I witnessed a very different kind of crisis leadership. This time it was not political, but clinical. It was not about national response, but survival. It was a mass casualty situation. Six to eight trauma patients arriving at once. Every trauma bay full. Every medic, nurse, and physician operating at the edge of their training. The sound of controlled chaos filling every corner of the facility.

If you have never stood in a trauma bay during a MASCAL (mass casualty event), it is difficult to explain the intensity. Each patient had a team working rapidly and aggressively. Airway, breathing, hemorrhage control, lines, blood, imaging, surgical consultation. Every bay was an ecosystem of fast decisions and coordinated activity.

In the middle of all this was the Trauma Czar. Unlike everyone else, he was not elbows-deep in one casualty. He was not tied to one set of vital signs, one airway, or one set of wounds. He moved almost effortlessly among the trauma bays, quietly observing, listening, and assessing. He was close enough to understand what was happening, but distant enough to see the entire picture.

At first glance, you might mistake his calm for detachment. It was the opposite. He was absorbing everything. He was watching each team’s progress. He was noting which patients were responding, which were deteriorating, and which interventions were buying time. He was not driven by urgency. He was guided by clarity.

And when it was time to decide who went to the operating room first, he stepped forward. He had the strategic view. He understood which surgical priority would save the most lives. He was able to make the hardest decisions because he had refused to get swallowed by the chaos.

That is the essence of leadership under pressure. Know what requires your hands and what requires your mind. Know when to step in and when to step back. Know when to influence the system and when to let the system work. Great leaders do not react. They interpret. They decide. They guide.

The Leadership Principle Behind Both Moments

Whether you are a President navigating an attack on the nation, a Trauma Czar orchestrating clinical survival, or a hospital leader dealing with a staffing crisis, the principle is the same.

The first ninety seconds are where you establish control, not through emotion, but through presence.
They are where you signal to your team that the situation is manageable.
They are where you prevent fear from becoming the dominant force.

In healthcare, leaders face their own versions of crisis daily. A code in the ICU. A critical shortage of nurses. A system outage. A medication error with downstream implications. A patient complaint that exposes systemic issues. These moments do not always look like trauma bays or global emergencies, but the leadership demands are the same.

You must be calm. You must be observant. You must be deliberate. You must be decisive.

Leaders who master those first ninety seconds set the tone for their teams and protect the mission. Leaders who spin up, react emotionally, or rush into action without clarity create more problems than the crisis itself.

How Leaders Can Train This Skill Today

The ability to lead calmly in the first ninety seconds is built over time. Healthcare leaders can start with three simple practices:

• Create the habit of pausing before acting.
• Train yourself to scan the environment rather than fixating on one problem.
• Build routines that help your team know exactly what to expect from you in pressure.

These are foundational competencies I coach leaders on every day. They are learnable. They are practical. And they separate leaders who survive from leaders who succeed.

If You Want to Strengthen This Skill

If you want to build the ability to lead with composure under pressure, this is a core part of my one on one leadership coaching for healthcare executives and rising leaders.

You do not need perfection. You need clarity confidence and presence in the moments that matter.

Book a leadership coaching session and we can start building those skills together.