The Size of the Bite; Managing Stress in Emergencies

‘You never seem to get too stressed out’, one of the nurses at my work recently told me, ‘why is that?’ It got me thinking, why don’t I seem stressed out, what am I doing when I do get stressed out at work? Certainly there are times when I feel stressed, but because I believe that an uncontrolled stress reaction can be detrimental to my ability to do my job I have found ways to turn down the gain when the stress is high.

In the emergency department stress is everywhere, from the critically ill patient in septic shock, to the patient with a sprained ankle. Every patient in the department is having a bad day, and every one of them is stressed out. Some doctors love the stress, the air around them glows as their very nature of being elevates surrounding electrons to higher energy states.

Stress itself can be a useful response, it can hone thinking and actions and when used appropriately can elevate your game. When stress degenerates into panic or frustration however it becomes just another obstacle to be overcome in an already difficult situation. As a physician in a busy emergency department often with single physician coverage I believe stress management is an important part of my job. It would be easy to become overwhelmed and over-focused on any of dozens of things in an individual shift. Emergency physicians working in an environment that is frequently stressful (probably 99% of us) should employ active strategies of stress reduction throughout our shifts. This increases our job satisfaction and it also increases patient care.

By now some of you are thinking ‘This guy lives n the west coast, he probably has a little yoga-meditation room at his hospital and sees 1 patient every 2 hours!’ Nothing could be further from the truth. The type of stress reduction I am talking about happens as you work, and it allows you to work better and faster.

Step 1: When the temperature in the room goes up, my temperature will go down. When the patient, the nurses or other physicians are getting increasingly overwhelmed, agitated, and stressed the situation becomes dangerous. The potential for medical error and misadventure is high at these moments. This group stress response can feel like a tornado and it can be tempting to allow yourself to be sucked into that vortex. Resist. When everyone else is stressed force yourself to speak calmly, slowly, with little intonation. Do not yell, but if you need to you may start out by saying in a firm voice ‘Everyone listen to me, this is how we will begin…’ Set (or reset) the tone of the room, the tone you want to project is calm confidence (even if you do not feel confident).

Step 2: Identify the person in the room who is the most stressed out and give them a task. If this person is a nurse, you need them to go draw up a med or start an IV or do some other useful task. You need to choose something that is simple and tangible and will redirect their focus away from the stress of the situation. If this person is a family member, give them a pen and paper and ask them to write down what they think is important so it will not be forgotten. If this person is the patient place your stethoscope on their chest and tell them you need them to give you 10 slow breaths while you listen to their lungs.

Step 3: When the whole situation is overwhelming break it down into smaller bites. An ambulance arrives unexpectedly and the paramedic runs into your resus room holding a child who has just been run over by a car. The situation is overwhelming, people are screaming, what do you do. This situation is emotionally charged and overwhelming, it would be easy to get caught up in the panic. Really we know nothing about the patient aside from the fact that there is a potentially devastating injury. The totality of the situation is overwhelming from both an emotional as well as a practical perspective. In a situation like this the best strategy is to step away from the totality of the situation for a moment, and take a small very manageable piece to start with. In situations of critical illness these initial first steps are the same regardless of the illness or injury. These initial first steps; put oxygen on the child, immobilize the C-spine, establish IV access, offer an opportunity to reset the tone of the room. Although these first steps take only moments if they are directed with calm confidence they will de-escalate the room and allow the remainder of the resuscitation to proceed calmly. When you personally feel stressed or overwhelmed it is useful to simply think of the next 1 or 2 things that need to be accomplished and then execute these very short term goals. Usually this will reset your internal stress level and allow you to again assert a calm confidence into the situation.

Stress is a useful response and it should not be ignored. Many of us in emergency medicine are here because we enjoy stress, and thrive in a world of high stakes decision making. Stress can be one of our most useful tools in emergency medicine, but for all of us there are moments that threaten to overwhelm our capacity to cope and degenerate into panic. Whether it is a failed airway, an injured child, or a difficult patient encounter using active techniques to manage stress will improve both your situational responses as well as your patient care.

The time and action specific consultation

As emergency physicians we spend a great deal of time interacting with consultants, but we don’t think about this as a skill. In fact we probably interact with fellow physicians more than any other specialty, but rarely is the interaction itself included in any type of formal curriculum. The well being of our patients often depends on our ability to get a particular consultant involved in a case.

Each emergency doctor has their own approach to consultation, from the buddy-buddy type of interaction to the frankly hostile. When junior physicians call consultants they often simply state what sort of case they have and see what the consultant has to say; ‘I have Mr. X here, a 65 year old man with chest pain….’ Unfortunately this leaves the consultant in the position of guessing what the emergency physician (and the patient) wants or needs. The consultant may respond with management advice when what the emerg doc really wanted was for them to come see the patient in consultation or accept the patient for admission.

A better system is the time and action specific consultation. This allows the emerg doc to clearly communicate their request to the consultant in a way that is non-confrontational, but also unambiguous. The phone call opens with an introduction; ‘Hi I’m Dr. J in the emerg, who am I speaking to?’ This allows both parties to know exactly who they are dealing with. Then (after the exchange of niceties that are an important part of collegial community practice) the emergency doc briefly summarizes the case and makes a specific request of the consultant and gives a specific timeframe.

An example might look like this:

“Hi it’s Dr. J in emerg, who am I speaking to?” “Oh hi Dr. Cardiology, happy new year! Listen I have a 65 year old man with chest pain, unresponsive to nitro and morphine. He has some ischemic ECG changes. I’d like you to come down and see him in consultation in the next 15 minutes.”

When you need advice rather than in person consultation it is equally important to say so:

“Hi it’s Dr. J in the emerg, who am I speaking to?” “Oh hi Dr. Opthalmology, thanks for calling me back. Listen, I have a contact lens wearer with a corneal abrasion. I’d like to put him on antibiotics, but he is allergic to quinalones. Can you recommend an appropriate non-quinalone antibiotic for corneal abrasion in a contact lens wearer and see him in follow-up tomorrow?”

The time and action specific consultation allows the emergency doctor, who has seen the patient, to set the pace of the consultation. This is appropriate since the emerg doc has the best idea of the actual acuity of the patient, but can be lost when the conversation lacks specificity. Most of the time your consultants will appreciate the brevity of your patient presentation, and directive approach to consultation.

Disagreements will occur and will mostly be about the need to see the patient or the timeframe within which they should be seen. When this occurs I suggest first identifying the conflict and then giving the consultant more clinical information to explain why you have made a specific request. Suppose the opthalmologist in the above example suggests a 1 week follow-up;

“Thanks for the advice Dr. Opthalmology, I will start the patient on gentamicin drops right away. I see we have a difference of opinion about when this patient should be followed up; this patient is a contact lens wearer and he has a large corneal abrasion right in the centre of his visual axis. It looks deep. I am worried about this patient so I think he should be seen tomorrow, rather than in a week.”

Most consultants will grant your request once more information is given. Occasionally the conflict will persist and negotiation will be required. When this happens remember to be polite, but also remember that your primary responsibility is to your patient.

Finally I suggest closing the loop, briefly repeat the plan back to the consultant and make sure you are both on the same page. Then document on the chart the consultants name, the action, and the timeframe.

“Thanks Dr. Opthalmology, I will put the patient on gentamicin drops and have him call your office in the morning for an appointment tomorrow.”

In summary a managed approach to conversations with consultants can benefit both parties, by expediting conversations, and making expectations clear from the outset. Managed conversations leave less room for ambiguity, assumption and error. The steps to the time and action specific consultation are :

  1. Identify yourself and the consultant
  2. Give a very brief summary of the case
  3. Ask the consultant to perform a specific action (advice, in person consultation, admission, etc.)
  4. Tell the consultant the time frame in which you need them to perform this action
  5. Identify and resolve any disagreement or conflict
  6. Close the loop by repeating the specified plan and time frame back to the consultant
  7. Document all of the above for the chart and the patient