When a critical patient lands on your department’s doorstep without prior notice, even the most seasoned professionals can find themselves momentarily at a loss — wondering what steps to take first and how to prioritize actions in those crucial initial seconds. What do I do first, what do I do next? What’s REALLY important in the first few seconds? In this episode, emergency intensivist and physician coach Scott Weingart breaks down how to get your mind unstuck and move into action.
Guest Bio: Scott Weingart, MD, is a physician coach and emergency department intensivist from New York. He did fellowships in Trauma, Surgical Critical Care, and ECMO. He is best known for talking about Resuscitation and Critical Care on the EMCRIT podcast, which has been downloaded > 40 million times.
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3 free resources specifically designed to address pain points in emergency medicine practice
- Scripting your least favorite conversations
- The quick and dirty guide to calling consults
- My 4 favorite documentation templates
We Discuss:
Temporizing vs. Stabilizing: Why Seconds Count but Don’t Really Count
- Use temporizing to gain time for collecting thoughts, preparing equipment, and moving to definitive action
- Make temporizing a reflexive action, requiring no conscious thought
- Stabilize the patient briefly during temporizing to allow for organization and planning
The Emergency Action Drill
- Reflexive actions built by practice such that you don’t need your type two thinking system to engage. Design reflexive actions that bypass active cognitive processing for emergencies.
- Automate responses, like hooking up a defibrillator for STEMI patient who suddenly goes unconscious
- Integrate drills to ensure they occur automatically in high-stress situations.
- Practice these drills regularly to ensure instinctive responses.
- Implement drills for managing immediate crises and allowing time for comprehensive care and cogitation
Get Off the Spot: Taking Action to Get Out of the White Noise
- Initiate action to disrupt the freeze response, begin cognitive processing, regain control, and stimulate the brain to think of next steps by breaking the cycle of inaction
- Provide new decision-making inputs by acting, even if imperfectly.
- Change the situation by moving or doing something to overcome paralysis.
The perturbation of the chaos that that action causes, whether it helps or not, will give further stimulus to let your brain say, what do I do next?”
Beat The Stress Fool: Breathe, Self Talk, See (Mental Rehearsal), Focus with a Trigger Word
How to Use Operant Conditioning to Train a De-escalating Trigger Word
- Associate a trigger word with successful, calm states during procedures.
- Strengthen the word’s effectiveness by using it in both calm and stressful situations.
- Personalize the trigger word for each clinician’s practice and mental framework.
- Regularly use the word in positive contexts to enhance its calming association
You Don’t Need to Be Everything, Everywhere, All at Once: The Critical Steps to Start Unfreezing
- Focus on basic actions like Airway, Breathing, Circulation (ABCs) in emergencies.
- Prioritize tasks to avoid overwhelming situations.
- Incorporate emergency action drills into routine for efficiency.
The transition from temporizing to definitive care in a trauma arrest
- Podcast link with a detailed walkthrough
Why ACLS Fails as an Emergency Action Drill: Strategy vs Logistics
- ACLS is strategic, not logistical, which is why so many codes go awry
- ACLS will tell you how many joules of defib current am I going to use? But that doesn’t help you with the patients in a pool of their own vomit and proned
The Reason Why Cognitive Freeze Happens in a Zero Warning Critical Situation
- Cognitive freeze is mostly a matter of unpreparedness and past chaotic experiences.
Cognitive freeze is because your E. D. and your mind hasn’t been prepared… all the other resuscitations you’ve done over the past three months that have been just strewn with chaos and you’ve been willing to accept that. Your system is failed.”
Crafting Your Own Emergency Action Drills: The Difference Between Thinky Time and Pure Action
- Identify key actions for common emergencies to build emergency action drills.
- What actions REALLY need to happen in the first moments of a crisis, the things that will bridge the gap to definitive action?
- Mentally simulate and practice these scenarios in real settings like the resuscitation bay
- Emergency action drills are involve logistics. Knowing where things are located and how you will use them are as important as the plan itself.
- Visualize and rehearse responses to various emergency scenarios
Building an Emergency Action Drill from the Ground Up for a New Disease
A Hospital’s Resuscitation Readiness Contributes to an Individual Clinician Freezing in a Zero Warning Situation
Making an Emergency Department Resuscitation Ready on an Individual Level
- Ensure readiness for emergency scenarios by organizing equipment in advance. For example:
- Set up a fully operational suction unit at the beginning of each shift (check with your hospital to make sure this is OK with them as it could conflict with Joint Commission recommendations).
- Assemble a BVM, attach a peep valve, and ensure it’s connected to the oxygen supply.
- Arrange intubation equipment on a mayo stand, marked as ready for use.
- Consider creating a dedicated intubation bag to have all necessary tools in one place
Emergency Department Resuscitation Readiness on a Systems Level: The Four Steps to Become a Resus World Champion
- Develop a mindset of ownership and proactive preparation for emergencies.
- Transition from discussing strategies to implementing logistical solutions.
- Collaborate with nurse and physician leaders to improve systemic readiness.
- Present low-cost or no-cost strategies to the administration for better patient care.
- Create a culture of preparedness that enhances care for every patient, even in unexpected scenarios.
Potential Objections to Becoming Resuscitation Ready
- Address common objections, such as regulations against pre-setting equipment.
- Demonstrate the benefits of improved readiness to overcome resistance.
- Implement strategies for making systemic changes on a budget.
- Work with hospital administration to implement necessary changes for better patient care.
- Overcome objections by showcasing the positive impact on patient care and outcomes.
How to Communicate Uncertainty in a Critical Situation
- Openly acknowledge uncertainty to the team to aid in diagnostics and treatment.
- Invite suggestions and ideas from the team to assist in patient care.
- Handle suggestions that may not align with evidence-based practices with validation, but do not say yes just to be nice. Defer discussion until after the situation has resolved.
- Balance team input with adherence to medical best practices.
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