The Pre-brief
In our previous conversation we covered the art of the deep breath and how beneficial this can be to clearing your mind and preparing it to receive and act on rapidly given information. In this post, I wanted to focus on how to develop the leadership skills that are so vital to success in the ICU.
Let’s rejoin you, the heroic ICU intern, on your first day in the ICU.
It’s now 3 PM on the unit. Rounds are over and you’re just about to head over to your mandatory lecture. A nurse comes up to you and mentions that your other patient, Mrs. T, is having a lot of trouble breathing. She was admitted for a bad COPD exacerbation several nights ago, and was intubated. She looked very well during morning rounds, so your team made a decision to extubate her to BiPAP. Remembering your lesson from the morning, you take your deep breath…
… and then go see the patient.
Mrs. T is indeed looking rough. She’s breathing about 40 times a minute and isn’t really able to talk to you because she’s working so hard to breathe. You notice that she isn’t on her BiPAP, just a nasal cannula, and she’s breathing rapidly through her mouth. Her O2 saturation is 84% and she looks like she’s about to go downhill very quickly. How are you going to react?
A) Run over to the bedside and turn the O2 as high as it can go. Panic when you realize that you don’t actually know how to get those darn nasal prongs to stay in the nose. Then, sprint down the hallway to wildly search for the BiPAP so you can throw the mask on Mrs. T.
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B) Oh boy… you really don’t know what to do here. Maybe you should give more oxygen? Maybe you should try a treatment? Put her on another breathing apparatus? What if that doesn’t work and she gets worse? Realize that there is now an awkward silence in the room and everyone is staring at you waiting for you to say something.
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C) Take a breath (a deep one) and ask the nurse to get extra help, specifically the respiratory therapist. In the meantime, place the patient on a non-rebreather, and once the RT arrives, ask them to place the patient on the BiPAP. Ask your RT to nebulize ipratropium/albuterol for the patient while asking your RN to give the patient IV steroids. Continuously monitor the patient to make sure she gets better. Lecture can wait.
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D) Scream at the nurse for not extubating the patient to BiPAP like you ordered. This is a huge mistake and the nurse should be punished, because they clearly messed up!
A is wrong because, although you may need all that equipment, there is no need for one person to run around trying to find all of those things. A good leader is able to delegate tasks to other members of the team with open communication.
B reflects a panicked mind that appears to be paralyzed with fear. Although having these worries about a crashing patient is completely normal, one must never allow doubt and fear to lead to inaction, especially in the ICU. This is where taking a deep breath can really be a nice way to interrupt the panic cycle and refocus your mind on the crashing patient in front of you.
D is VERY wrong. First off, we don’t know the circumstances that led to the patient being off BiPAP. It could be that she was not tolerating BiPAP and ripped it off, so the nurse placed her on a nasal cannula. It could be that the order was never communicated effectively. Even if a mistake was made, assigning blame and reacting in anger never accomplishes anything, and nobody learns from the mistake. When a mistake is made, most hospital systems have a way to report it and not assign blame for the mistake. This method should be utilized to create systemic changes that will prevent similar mistakes from happening again.
Hopefully it’s obvious why C is the answer. The patient is in acute distress and could rapidly deteriorate, but keeping your head calm and clear will help you, your team, and the patient more than anything. As reflected in the incorrect answer explanations above, a good resuscitationist will be able to effectively delegate tasks to the team and keep lines of communication flowing amongst team members. There also is no role here for reacting in anger at a perceived mistake, especially if the patient is deteriorating in front of you.
15 minutes later, Mrs. T is not doing well. She is not tolerating the BiPAP, and keeps ripping it off, which causes her oxygen saturation to drop to the high 70’s. You put a page out to your attending, and turn to the nurse and say, “I think we need to intubate Mrs. T, can you please get the airway kit?” Various members of the team get all the equipment needed ready, and your attending shows up to supervise. As you are getting ready to ask the nurse to push the sedative and paralytic, one of the other nurses says “her blood pressure is 95/70… do you want to give fluids or have push-dose phenylephrine ready?” Once again, we have some possible choices here.
A) Turn bright red with embarrassment, hang your head in shame, and hand over the mac blade to your attending to let her intubate. You are ashamed for forgetting to check the blood pressure prior to pushing the meds. Hang your stethoscope up on the doorway as you exit in dramatic fashion.
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B) Get flustered at the audacity of a nurse to speak up during such an important procedure. How dare they interrupt during such a vital time! Proudly say “I’m the doctor here, PUSH THE MEDS!”
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C) Thank the nurse for making a great observation and speaking up about patient safety. Ask for some fluid to be started, and ask the nurse to please get push-dose phenylephrine to the bedside just in case it is needed. Make a mental note to remember to notice the blood pressure next time and add it to your checklist.
Again, C is clearly the way to go (if only our board exams were like this). Being a good leader means recognizing that every member of the team has valuable input to contribute. This is especially true in the ICU setting, where each patient has critical illness that has the potential to be life threatening. Each member of the care team contributes valuable information to patient care, and you as the resuscitationist or intensivist should welcome input with open arms.
One should not feel embarrassed that another member of the team thought of something that you did not. In the same vein, one should never feel such hubris as to ignore suggestions just because it may make them look bad. When someone has a concern, it should be taken seriously and that person should not be faulted for speaking up. Disagreements about plans of care may take place, however keeping open lines of communication usually has the positive effect of making sure every member of the team understands the reasoning behind the plan of care.
I have been lucky to train in systems where there is multidisciplinary rounding, so each member of the patient care team meets and rounds when the physician team rounds. In this way, all concerns are addressed, and each member of the team has a chance to bring up issues or suggestions for patient care. I’ve also been lucky to train with physicians who valued input from all members of the team and were able to integrate this input into the overall plan of care for the patient. On the contrary, I’ve also seen situations where no input was sought and have seen first-hand how fractured a team can get if the leader does not value input. Ultimately, the patient is the one who suffers in these cases.
The Debrief
We know how stressful being a leader is, especially when taking care of critically ill patients or patients deteriorating right in front of your eyes. During these moments, we hope that the points brought up in this article will help you lead your team effectively through these situations and help keep your patients alive.
- Keep a calm mind during the most stressful situations.
- Keep open communication flowing among the team and delegate tasks effectively.
- Do not react in anger to perceived mistakes, especially in front of a crashing patient.
- Remain open to suggestions without being too full of pride. Ask for help when it is needed.
Are there any aspects of leadership that we missed? Any other tips that you may have to pass on? Please leave a comment and tell us… we’d love to hear them!
