The Top Five Rules of the ICU

It was 9:30 PM. I was alone in the ICU. The patient for which I was caring had just had heart surgery. He was getting agitated, and so I ordered a common medication to treat his agitation. Then, suddenly, he turned blue because he was struggling to breathe.

“Call a Code!” I screamed to the nurse. I needed others to help me in this emergency situation at night in the ICU.

I then placed a breathing tube emergently into his airway to save his life. Thank God, he did fine, but it was a very scary few minutes. I found out later that the medication I had given caused his vocal cords to spasm and close off his airway. It was an extremely rare side effect.

If you could see me on the inside, I was in complete and total panic. I was screaming…on the inside. On the outside, however, I was as calm as can be.

Which leads me to my Top Five Rules of the ICU. Whenever a resident or medical student starts a rotation in the ICU, I talk about these top five rules:

1. Don’t Panic
2. Don’t Panic
3. Don’t Panic
4. Don’t Panic
5. Don’t Panic

In the ICU, things can happen suddenly – just like that patient’s vocal cord spasm – and the only predictable thing is that it is unpredictable. A patient can be fine all day, and then all of the sudden, the blood pressure can drop and the heart can just stop beating. We have to act quickly and decisively. We have to intervene aggressively. What we absolutely cannot do is panic.

Could I be panicking on the inside? Absolutely. But, on the outside, it is imperative that I not panic.

When we panic, we freeze in fear. In that fear, we are liable to not think straight and get overwhelmed by the horror of the situation. Furthermore, emergency situations in the ICU can get quite chaotic…because everyone else is panicking themselves. As the leader in the ICU, I simply cannot afford to panic. If I do, then I lose control of the situation, and the patient can get hurt.

Now, could I be panicking on the inside? Absolutely. Like I said, I was totally panicking with that vocal cord spasm situation…on the inside. But, on the outside, it is imperative that I not panic. It is imperative that I keep my composure, so I can maintain control of, not only myself, but the situation at hand so that I can benefit my patient.

Whenever I ask my students and residents about the top five rules of the ICU, no one has ever said, “Don’t panic.” I always get a chuckle at the various answers. But it is absolutely essential that we clinicians in the ICU do not panic, no matter the situation. It can literally be a matter of life and death.