I was perusing Reddit recently when I came across a post on the r/Residency subreddit asking for advice on running codes. Specifically, how to maintain calm as the leader in this critical situation. This led to self reflection on how I developed my own ability to maintain calm in critical situations. As an ob/gyn I don't run codes, but I consider a relatable obstetric emergency the management of a shoulder dystocia. In our field of medicine, this is a true emergency where seconds count and there is no room to panic.
As an intern, and still frequently as a second-year resident, my senior residents would take over when we encountered a significant shoulder dystocia. As I reached my senior residency years and started attending deliveries as chief of the service, I came to the realization that I had to take the lead while also recognizing that this obstetric emergency certainly brought out a feeling of panic. The time to pass the buck on this critical situation had passed; my team was looking to me to lead them through it and I had to find the ability to be the leader they needed. And I had to find it fast. I could not lead my team or take care of my patient if I let the panic I felt take over.
For me, finding this calm largely relied on reflection — both on personal past experiences and advice from superiors.
I knew I had the ability to be clearheaded in an acute situation. Although not life-threatening, this had been my experience in athletics. Prior to competition, I experienced feeling sick with nervousness, but when the competition finally started, I naturally switched to an almost serenely calm frame of mind that allowed me to focus on the task at hand. However, in this situation, I knew what was coming well in advance and this change in mentation happened naturally, without any conscious effort. I now needed to find a way to access this frame of mind on command.
I remembered a maternal-fetal medicine attending in my intern year saying that he felt the time it took for him to get into the room if called with a shoulder dystocia was beneficial to managing the situation. He did not believe this momentary pause caused any harm to the neonate, and also allowed the baby an opportunity to restitute into a better position. His insight gave me the permission I needed to take a moment to get control of how I was feeling.
I also recognized situations where I had seen my superiors, both senior residents and attending physicians, perform poorly out of panic. There is a postpartum hemorrhage event that will always be a memorable learning experience for me because post event debriefing made it clear that my superiors' panic compromised their understanding of the clinical situation. I saw how this led to an unclear comprehension of what actions had been taken and an inability to appropriately assess the situation. This ultimately led to poor leadership of the team that had the potential to worsen the outcome for the patient. Luckily, in this situation, the patient did receive necessary care and had a good outcome, but debriefing proved that the path to getting there should have gone more smoothly.
As physicians, when we encounter these critical emergencies, we owe it to everyone to get control of our own emotions. It is a necessary part of the job. But it is not a part of the job that can necessarily be taught. Our mentors can lead by example and show us how we need to behave in our role. If they are aware of how they achieve the mental control over themselves needed to manage the situation, they may be able to share their insights. But each one of us has to ultimately find the ability to be "the calm in the storm" for ourselves. And while this will come more innately to some, it can be helpful to approach it as a skill, just like developing a differential diagnosis or learning a new procedure. And just like any skill, the more we do it, the better we become at it.
The next time I found myself with a shoulder dystocia situation, I stopped for a moment and found myself taking a calming breath. That simple act was enough to quell my panic and proceed in a rational sequence to resolve the situation and complete the delivery. Over the following months as I utilized this coping strategy, I became better at accessing the necessary frame of mind on command. I became a better leader and a more confident physician.
In an acute emergency, it feels like every second counts, which can make it feel as though taking this moment is wasting precious time. But taking this step is important precisely because every second does count, and not all actions are equal. Every step taken, every assessment made, needs to be made with a clear mind that can ensure it is the correct assessment and the best action. There is no time to allow for panic to take control of the situation. The moment I use to get control is not clinically harmful and makes all the difference in ensuring that I find the presence of mind to move forward rationally and resolve the emergency as quickly as possible.
This is still how I practice to this day. A shoulder dystocia is where I most clearly feel its impact, but I do not just utilize it in the delivery room; I have brought it into the OR, the ED, sometimes even just at my desk getting an unexpected or concerning result. In all areas of medicine, the weight of our clinical decisions can be heavy. We are presented with emergencies and the choices we make can impact our patients for the rest of their lives. Our patients deserve decisions that do not come from a place of panic but a rational approach to resolving their emergency. A small act, like taking a breath, can be a powerful tool toward giving our best in the most critical moments.
How do you stay calm in emergencies? Share your best practices below.
Dr. Erica Jacovetty is an ob/gyn practicing in Maine. She enjoys reading, pie making, and gardening. Dr. Jacovetty is a 2024-2025 Doximity Op-Med Fellow.
Image by Isaeva Anna / Shutterstock
