“At a cardiac arrest, the first procedure is to take your own pulse.” This oft quoted line from House of God is not unique to medicine, but applies across a wide swarth of life. The first question to ask when approaching an emergency is assessing the area for safety. Nothing turns a bad situation even worse as quickly as increasing the number of patients and decreasing the number of providers in an instant. After that, only two things are critical within the first handful of seconds. The first is to call for help and make sure that more assistance is on the way. The second is initiation of high quality CPR to keep key organs such as the brain perfused. After that keeping your own heart rate low, your mind clear, and your attention on the task at hand becomes the only concern.
For teams that are well versed in running these codes there is often a feeling of calm, a rhythm that is rapidly ensues. Each person knows their role, the basics are covered with such precision that higher level thinking including methodical consideration of the underlying physiology can be done as the basic algorithms are already covered. The first time doing chest compressions, one of the attending physicians pulled out a pocket metronome to help me keep pace. For teams that are less familiar with codes or are not consistently working with high acuity patients, there is a frenetic pace to the code. A feeling of rapid movement, albeit with little forward motion, is tangible. Often very specific directions must be given to delegate tasks, ensure that proper medications are given, and to keep everyone on the same page. The frenetic activity results from the feeling of panic that those arriving may feel and the desire to do something, to do anything.
Frenetic activity is the default. Often it even feels good. Activity provides a distracting sensation. In less urgent situations pacing, tapping on the desk, or other manifestations of frivolous activity may be permissible. In the situations which truly count, this frivolous activity is unacceptable. Steady hands and clear minds are inhibited by background motion and good communication is broken down by the cacophony of background noise.
Rejecting meaningless motion, high paced but trajectory less activity, is essential. Being anti-frenetic in these moments is a choice, plain and simple. An anti-frenetic attitude does not mean that one is confident that a good outcome is guaranteed or that a serious problem is not present. In many cases a good outcome is far from guaranteed and a serious problem is definitively present. Freneticism is the antithesis of communication, teamwork and progress. Being anti-frenetic means recognizing that panic, high velocity flailing, is of little value and that the best chance for a good outcome is rejecting fear and the sensation of panic welling up in ones throat and choosing purposeful, meticulous activity with good communication and an emphasis on teamwork.
Take your own pulse. Reject fear. Suppress panic. Do your job.