How to be whelmed

Staffing models in the ICU vary widely, which means that as a clinical provider, you might need to look after one critically ill patient or a dozen. I’ve worked in units where, with the assistance of only one other provider, I routinely had responsibility for over 20 patients, and while it wasn’t easy (okay, it was too many), we managed.

However, the more tight your staffing, the more susceptible your workflow to insults and perturbations. When more hours in a shift are already filled by routine activities, such as rounding and writing notes, the less wiggle room is held in reserve for “surprises.” These little gifts, such as admissions, emergencies, and procedures, are not really surprises—this is an ICU, after all—but they cannot really be planned for, because they cannot be foreseen.

So: you are one person, and you have four notes to write and two patients to transfer, as well as a central line to rewire and a family member to update. Then, the ED notifies you about two sick patients simultaneously needing admission, one of your existing patients becomes hypotensive, and a rapid response is called on the floor for a patient in respiratory distress. Multiple problems, yet still only one of you. In these situations, it’s easy to become overwhelmed.

Finite resources are a reality, and usually an inevitable one, as even when staffing is luxurious, needs can always grow to exceed them. Despite this, surge situations are usually manageable with a sound, flexible approach. The one thing you can’t handle is becoming overwhelmed. Once you upset your mental kayak, it’s likely you’ll not only fail to meet your surge needs, but also fail in your routine obligations.

As Osler would say, you require equanimity. Put more prosaically, you must never become overwhelmed. Of course, neither should you be underwhelmed; “low energy” types don’t get much done. You must—without exception—whatever the situation—merely be whelmed.

Here’s how.

It’s all about priorities

In routine situations, when tasks arise, you simply complete them, from A-to-Z, beginning to end, soup to nuts. When an admission presents, you evaluate the patient, enter all the orders, write a note, and that’s that.

What do you do if you have four admissions at the same time? You could follow your normal approach… but that would likely mean one patient receives thorough, comprehensive medical care while the others receive no care at all for the next two hours (whilst as you leisurely compose an epic H&P).

The better solution is to prioritize, and that means stratifying your obligations—not by importance, since everything is “important,” but by urgency. Many things need to be done, but not all right away. If four patients need admission, what is it they require? The person in respiratory distress needs to be placed on BiPap. The person in shock needs vasopressors. The person with an MI needs a consult to Cardiology. Those are all time sensitive, mortality- and morbidity-preventing interventions that need to occur quickly. But there aren’t very many of them, and you can get them all done in a handful of minutes.

Lots of other things also need to happen, but they can wait. Taking a thorough history, reconciling home medications, placing a central line for reliable access… they all may need to be done eventually, in some cases need to be done within hours, occasionally need to be done in the next 30 minutes, but if they don’t need to be done right at this moment, they can wait.

Focus on the things that will save a life and you’ll discover you have more time than you realize, because in reality, there aren’t very many.

A system

Here, then, is a universal rubric for task triage, from most to least urgent. Like all rules, it has exceptions, but it will get you pretty far.

  1. Acute emergencies: treating life threats such as shock, hypoxemia, or hemorrhage.
  2. “Time sensitive” care: anything that doesn’t need to be done immediately, but where time matters. This includes many actions where there are inevitable delays between starting the ball rolling and its actual effects, or which serve as a prerequisite for other things. For instance: giving a diuretic, requesting an x-ray, calling an important consult, or ordering an antibiotic that needs to come from the pharmacy. (Transferring out patients often falls here too, because it may make room you need to treat other patients.)
  3. Very quick things: anything you can complete within a few seconds. Just getting it done is better than making it wait for three hours.
  4. Personal essentials: eat, sit, use the restroom. These are flexible but if ignored entirely start to cause problems.
  5. Routine care: things that need to happen today, but not in the next hour. For instance, ordering home medications or stress ulcer prophylaxis, placing a clean line, or calling a consultant to clarify their plans.
  6. Documentation and non-clinical tasks: things that can happen anytime, with no impact on patient care. Writing notes, updating sign-outs, billing, and so on.

Following this system, the order of operations for one of those sick admissions might look like this:

  1. Bolus fluid and start peripheral vasopressors for shock (treating emergencies).
  2. Draw cultures and give antibiotics, then do a quick bedside ultrasound and call the nephrologists about the potential need for hemodialysis (time sensitive).
  3. Sign a routine ECG handed to you for another, stable patient (very quick things).
  4. Grab a snack and have a pee (personal).
  5. Discuss the full story of the patient’s complex history with their family member and order a full treatment plan addressing their litany of subacute and chronic problems (routine care).
  6. Go and hide—an extremely useful trick for getting busywork finished—while you write an H&P, assign the patient to a team and provider, and bill for your time (non-clinical tasks).

Conclusions

It only takes one sick patient or lengthy procedure to suck several hours away from what was already a busy shift. You can view this as creating impossible situations—how can you fit a gallon of work into a quart jug?—but that’s a fallacy. The work isn’t static. It can be manipulated, and you’re its master.

Slice and dice your obligations so that important things get done on time, while unimportant things filter into the gaps left behind, and you’ll discover that actually, you can do just about anything.

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