Tag Archives: stress

on being called “a hero”

There’s a hazard to having a friend that’s a sociologist: she forces me to think about why things are the way they are. In this particular case, she’s turned me on to some interesting reading material that seems never to fail me for something to think about.

I am not unaccustomed to risky jobs, and the people who work in them. I work with paramedics, firefighters, prison guards,  the most commonly thought-of “life is on the line, he’s such a hero” sort of stuff. The book they’re talking about is right on the money: for the most part, they don’t think of themselves as anything other than ordinary people in control of an extraordinary situation. Any mishaps that laypeople consider to be risks inherent in the job (a cop getting shot, a firefighter dying in a fire) are not seen as particularly risky to the people engaging in them. I’ve spoken to cops about going into buildings armed against people who have gone totally butternuts and are armed to the teeth — the risks they talk about aren’t that they might get shot at — it’s the fact that butternuts in the shed over there isn’t predictable. They’re trained to predict what the rest of us think are unpredictable.

This, of course, thanks to the grooming of my friend the sociologist, makes me think of the times when I’ve been told I did something “heroic.”

Usually what happened is there was a very sick person in a very bad way, and I was part of a team of people who predicted the unpredictable and then responded. The response is to perform a number of different interventions in order to change the course of their illness or injury. I don’t think what I’m doing is heroic. I don’t think about how people are going to die if I screw up. I don’t feel the pressure, really. What I am is in control.

I can see the signs. I can measure and quantify how bad the situation is using specific parameters which allows me to manipulate those parameters with drugs or pressure or gas. I can control the oxygen or the respiratory rate. Sure, there’s a bit of a scramble trying to get to the point where you’re in control, when you’re on the move from prediction to execution, but you know what to do, so instead of being stressed about how it’s do or die time, you just stop thinking and do.

I find us RTs especially tend to think in “the worst thing that could happen is” sort of parameters. When others are afraid to extubate the patient we’re shrugging our shoulders going, “the worst thing that could happen is she/he gets reintubated.” To us, it’s no big deal. We’re trained to predict what the worst possible scenario could plausibly be, and then be prepared for it. We controlled the airway by putting in a tube, we did it once, we can do it again. If I can’t do it personally, there’s someone close by who can.

I remember a couple of these do-or-die situations happening to me and there was a lot of muscle memory in that st0p-thinking-just-do. A sick neonate thrashes a bit on the overhead warmer and self-extubates, and there’s no pediatrician within a shout’s reach? I’ve been trained for this. They taught me how to intubate precisely so that I could respond to this situation. Paralyzing myself with fear and waiting for the pediatrician to haul his ass into the room is an option, but the worst thing that could happen is I try and I miss. I’m also trained in what to do in that case: the patient would be no worse off for me missing. Besides the fact that I’m qualified and trained and skilled in intubation — the patient needs it right bloody now. If I waited for the pediatrician I’d feel like I had chosen the wrong line of work and would probably quit soon and go become an accountant. What I did was grab the (conveniently located) necessary equipment and make with the intubating. I know what has to be done, and I’m qualified to do it, so I do.

There are those times when despite your best efforts you lose control of the situation. Just like the firefighters do, I find we look for something to blame. Somebody screwed up, somebody didn’t notice the alarm, the monitor was malfunctioning, I gave up too soon and should have kept trying, we didn’t get there in time, they waited too long, and so on, and so on. I failed to predict the outcome. I failed to respond accordingly to the situation in the way in which I was trained. I look for how I could have gained control, therefore, I don’t really fear the loss of life that happens due to variables that are beyond my control.I learned very long ago as an RT that there’s some parts of the clinical situation that you just can’t change.

I’m scared of screwing up or missing something, I’m scared of missing the prediction or failing to respond. I’m also confident that the longer I spend in control and the more I refine my muscle memory, the more I lift the mental weights that allow me to consider more of the situation, the more that muscle memory allows me to automate simple tasks so I can spend more mental energy being observant to other signs, the less likely it will be that my simple screwup results in somebody’s death.

It’s happened in the past: I’ve failed to notice a sign that the patient was in cardiac arrest and then the patient died. That said, so did everyone else in the room fail to notice, and given how sick the patient was prior to going into cardiac arrest, the chances of us being successful even if we’d caught it were pretty slim anyway. No one person killed that patient. The culmination of many factors did, and some of them were beyond our control. Did I learn a hard lesson? Yes, I did. That one’s a notch on my proverbial shield that I’m not ever going to forget — and the next patient will benefit from it.

Therefore, by the same token, no one person involved in saving another’s life is “the hero.” The collective sum of our teamwork and brains and muscle memory and situational awareness and skills are the heroes. We just predicted the unpredictable. We executed our plan for how we were going to gain control. We gained control of the situation quickly and effectively, and then we held on to it. It holds no mystery to us.

We are comfortable.

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setting the tone

Tension is contagious. The job is stressful, what’s happening is scary, yes, but it’s sometimes in these situations that the most important thing you can do isn’t anything life-saving — simply put, you have to keep your cool.

Emergency is a department where you think you would meet some of the most resilient people in the world — people who are unflappable and good under pressure. Some, even the majority of them, are. Not everyone can be perfect, however, so it’s important that the unflappable stay calm, with an even tone of voice, without rushing. It’s precisely because tension is contagious that the naturally un-tense among us mustn’t get caught up in the tension.

Respiratory is a tense job, period. I’ve had moments I clearly remember primarily because of that squeeze of adrenaline burning the memory into my brain. The stress response is a strong thing: my hands shake, my speech is fast, pupils dilated, time dilated, memory sometimes not the most reliable. It’s a struggle in these moments sometimes to keep my tone of voice even, to not rush my words into an unintelligible mumble, to not get impatient to the point where I begin taking my stress out on other people.

It only takes one person to destroy the calm. Even when things are hairy and scary, voices don’t have to be raised, team members can ask for things (rather than demanding,) and tempers don’t have to be short. It’s when the one person who’s not in control, who lets tunnel vision take over, who lets their stress spill into their voice and their ability to cope evaporates in the tension. This person can be the most dangerous player on the team, simply because they stress other people out — those who don’t have iron fist control over their emotions — and it’s in this stressful state, with someone barking orders at you, yelling at you, that you begin to rush, and your judgment and decision making skills become impaired.

This is when experience helps — not because experience will tell you what to do, but because experience will make you harder to stress out, generally speaking.  The exception to that rule, of course, are those people that have a tendency to become flustered even with experience. It’s worse, because the less experienced team members pick up on this, and then end up in this situation of “if they’re freaked out, then I should be freaked out!” Things spiral into disorganized chaos from there.

I’m at the head of the bed most of the time. I have a very clear role to play and a specific job that is, truly, nobody else’s. Nobody in that room barks orders at me for the most part, and I don’t order anyone else around. Once I’m doing what needs to be done, everything else follows. In a sense, it’s tense at the beginning, but once airway is secured and air goes in and out, I am a spectator at the head of the bed. Maybe it’s what makes it easier to be calm.

This feature of the job allows me to fade in the background and observe people. I consider it a point of pride to remain collected and cool. While spectating, I take notes in my head — notes about the people around me and how they’re handling the stress. I think it stands to reason that the people I observe setting the tone, giving orders in even tones of voice, or focusing efficiently on the task at hand, tend to be the people I gravitate towards when the situation isn’t stressful and hairy. I find their resilience enjoyable, and for the most part, they’re also highly intelligent people who are exceptional at their jobs.

A lot of people start out with emergency medicine in mind thinking that they get to be a hero in those dramatized situations they see on television. The truth is that the best people for the job are the opposite — not trying to showboat their heroics, not making the situation into a dramatic cluster of chaos, but those who calmly go about the task at hand with focus and skill. The truth is, the best run codes are the ones where everyone in the room looks like they are just this side of bored. There’s nobody pressed with anxiety that things should be happening faster. The lack of tension means that it’s easier for everyone to take a second to think. And while in those situations speed is crucial, speed is useless if you haven’t had a chance to think.

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