The Vitals: The Deep Breath

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Sunil Ramaswamy
Sunil Ramaswamy
Hospitalist, Critical Care Fellow, guitarist, world-wanderer, and espresso enthusiast. Love all things critical care.

It’s 6 AM on the unit. You’re just about to start your first day in the medical ICU. The senior resident has divided up the patients, and you’re settling in to read up on Mr. J, who was admitted overnight for septic shock, when the nurse peaks his head into the workroom and asks, “Who has Mr. J?”

“I do!” you state, confidently.

“His pressure is dropping and the vent alarms are going off. I’m worried about him.” Unfortunately, your co-residents have all left the work room and you have nobody to look to for help!

What would you do in this situation?

A. Tell the nurse boldly “it’s 6 AM and his pressure dropping is probably ok because the patient is just waking up from his beauty sleep.”

B. Complain that you haven’t had your coffee yet, haven’t reviewed the patient, and you’re tired. You can’t possibly be bothered about this now.

C. Giggle nervously as you stare at the computer screen hoping a senior comes back to the room.

D. Say “I’ll be right there,” take a deep breath, and then  assess the patient.

Hopefully, we’ve all chosen D, although one could certainly see why B or C may be enticing. One of the best pieces of advice I received as an intern from a senior resident was to always take a deep breath before reacting to information, especially in the ICU. This helps me quiet my mind and prepares me to receive and process information calmly.

On your way to the room, your mind starts racing. Pressure dropping? Vent alarms? Septic shock?

You arrive at the bedside: Mr. J’s alarms are indeed going off. His blood pressure is 80/50 and his heart rate is 124. His oxygen saturation is 88% while receiving mechanical ventilation. The nurse starts telling you about his pressors while the respiratory therapist tells you the ventilator settings. There are noises everywhere demanding your attention. Everyone expects you to have the answers. How are you going to react?

A. Hit the silence alarm buttons and walk out of the room. No alarms… no problems!

B. Nod frantically while looking wildly from the RN to the RT as they both tell you information in what feels like a foreign language. Realize that you actually didn’t absorb any information about the patient and then panic.

C. Run up to the ventilator and start mashing buttons and twiddling knobs. PEEP? Sure! FiO2? More please! Then action roll to the medication pump and do the same.

D. Take a deep breath and calmly ask members of the team to give you information one at a time. Start with the ABC’s. While doing this, ask for someone to please call the ICU fellow and your senior resident.

Hopefully, we see that D is the way to go here. I have a confession to make … as an intern, I pulled a “B” during my first time responding to a similar situation. Luckily, my senior resident (the same one who gave me the pearl about taking a deep breath) was in the room next door, stabilized my patient, and gave me non-judgmental feedback about how to do better.
This is a fairly common scenario. ICU patients are critically ill and often have many issues happening all at once. When a patient takes a turn for the worse, a lot of things may go wrong at once. As someone new to the ICU, your ability to handle these situations may not be fully developed… and that’s OK! You wouldn’t be expected to know how to handle this on day one. Sometimes, the best thing you can do for a patient is to remain calm and call for help when you realize things aren’t working.

Your senior resident and the ICU fellow both arrive at the bedside and assess the patient. They calmly and quickly collect information from both the nurse and respiratory therapist, quickly adjusting the ventilator and vasopressor dose. The patient’s oxygen saturation and blood pressure improve. For the time being, he’s now stable, and you head back to the work room to debrief with your seniors and reflect.

The amount of information coming at you can be overwhelming, even for experienced clinicians. When I was an intern, the attending physicians, ICU fellows, and senior residents who I admired had the ability to calm the room and replace the frantic energy with organized efficiency.

Oftentimes, you will not know why a patient is crashing immediately, but if you’re able to remain calm in the setting of chaos, the team will sense that energy and function much better in critical scenarios. This will allow for an organized and efficient assessment of the rapidly deteriorating patient, and hopefully, will lead to a good outcome.

The next time you find yourself overwhelmed by a situation in the ICU, stop, and take a deep breath. Allow your mind to quiet itself before taking in the information about your crashing patient. A brief pause can interrupt the momentary feeling of panic, and will help you focus and remain calm in stressful situations. Panic is the enemy of the resuscitationist, and the deep breath is a simple tool to fight panic. Ultimately, if you can learn to keep your mind focused and still when there is chaos surrounding you, the team will function better, and hopefully your patient will have a better outcome. 

We’ll talk about how to function as part of the care team and how to develop leadership skills in future posts.


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