Check Your Own Pulse

The following is an article written by my dad, to be submitted for publication.

Check Your Own Pulse - by Dan Schneeweiss, M.D.

I have the mixed blessing of being in a profession that requires me to periodically manage emergencies in the operating room. I am an anesthesiologist, a profession described as “99% boredom and 1% panic”.

More accurately, it is 99.9% routine -- things sometimes happen unexpectedly during an operation, but we’re accustomed to anticipate and respond to such events. Generally, there is no immediate threat to the patient’s safety; we are vigilant and well trained. Generally, the cause is apparent, and the resolution is promptly initiated - “no harm, no foul.”

The remaining 0.1%, however, is “You better NOT panic” ... but more on that later.

In my 19-year anesthesia career, there have been a few cases that have tested my skill and fortitude to the limit. These are situations that deteriorate rapidly and place the patient’s life at risk. Out of the 20,000 patients I have cared, for I have had fewer than a half dozen of these. You never forget the details of such events.

I recently had one of these cases that was rather unique. In this “man-bites-dog” scenario, it was not the patient’s safety that was at risk, but rather my personal safety and the safety of my nursing staff. Briefly, this involved a six foot tall 260-lb. muscular young man who emerged from general anesthesia in an agitated state. Despite massive doses of sedative medications, his agitation rapidly deteriorated into a violent fracas requiring four nurses and myself to restrain a thrashing, punching, kicking, biting behemoth. He snapped his wrist restraints, tried to disconnect three safety belts, and bit through his IV tubing and monitor cables. He threatened to “track me down and f******g kill me” for restraining his arm in a rather painful position so that he would not harm himself or any of us. Eventually - for the first and hopefully the last time in my career - I called 911 for police back-up. I needed a “show of force” that a 62 year-old anesthesiologist and four female nurses (two of them weighing under 110 pounds) could not provide.

I could regale you with the details of this case that might amaze and perhaps even amuse you. But my purpose in writing this is to share with you the following principles as a guide in approaching not only medical emergencies but also emergencies in other settings.

1. “Check your own pulse.”

This quote comes from a book called House Of God written about life as an intern at Massachusetts General Hospital. A list of rules for interns contained the admonition that when approaching a cardiac arrest, the first thing to do was to “check your own pulse.”

Once you realize that you are facing an emergency, you must force yourself to remain calm and not panic. As difficult as this might be, you must not even give the appearance of panicking. Raising your voice beyond what is needed to be heard, using profanity, making harsh, critical comments, expressing fear and hopelessness -- such behavior adversely affects your entire team. Even if you FEEL panic inside, DO NOT let that feeling show. As the old deodorant commercial warned: “Never let them see you sweat.”

2. “Hope was not a plan.”

This is what the CEO of JetBlue Airlines said when asked what he had learned from the disastrous incident several summers ago that left JetBlue’s planes on the tarmac in the blazing heat for over eight hours, passengers stranded inside.

It is natural to avoid facing an unpleasant reality. It is easy to delay going into action in the hope that things will improve. To make matters worse, it is not always easy to recognize when a problematic situation turns into a crisis. This transition may be gradual, with no clear demarcation.

However, once you recognize that the present situation is spiraling out of control, you must immediately change your mindset to deal with the true emergency. You must improvise a plan and act on it. Just hoping it will get better again will only waste time.At the same time, you must avoid over-reacting to minor mishaps. Over-reaction and delayed action are both harmful.

3. “Sometimes wrong, but never in doubt.”

Better known as the Surgeon’s Credo, this means that you must act decisively and never give in to becoming mentally immobilized. This can be VERY difficult. The scenario is: you improvise a plan based on your experience with similar problems. You go through all of the normal prescribed steps but ... IT DOESN’T WORK. Suddenly, there is a danger of becoming psychologically immobilized just as that panicky feeling sets in.

You MUST fight that feeling. You MUST be decisive and act. There is a very important principle here: better a wrong action than no action. Even if that action might turn out to be a mistake, at least a mistake might give you information about what doesn’t work. Decisive action will give your team confidence in your leadership. If you freeze, others start to panic.

4. “Think outside the box.”

You might also need to resort to unorthodox options to resolve the problem. In the emergency I described earlier, I finally called 911 for police back-up. That’s not something one ordinarily expects to do in a medical setting. I also resorted to a rather unusual choice of medications. When the routine sedatives did not work, I asked for the drugs used to tranquilize violent psychotic patients. They were not available at the facility where the problem occurred. I then remembered a medication that has fallen out of favor as a sedative in anesthesia more than twenty years ago. I used it and it worked.

Also know that your leadership is not compromised by listening to suggestions from your team. You may be the person in charge of the situation, but don’t be ashamed to seek advice and help from others who might approach the problem from another perspective based on their own experiences.

Finally, when the emergency is over, debrief with your team. Review your management of the event, and discuss suggestions for improvement. Remember: “Good judgment comes from experience ... And experience comes from bad judgment.” No matter what the outcome, thank your staff for their help. The experience has likely been traumatic for the staff. No matter what the outcome, they tried their best.

To summarize:

• Check your own pulse. Stay calm or at least appear calm.
• Hope is not a plan. Don’t lose precious moments to inaction in the hope that things will get better.
• Sometimes wrong but never in doubt. Don’t freeze. Be decisive. Action is better than inaction.
• Think outside the box. Creative solutions may be needed.
• Debrief and thank your staff. Graciously acknowledging the efforts of your staff creates a loyal and cohesive team.