Freezing During Critical Situations

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I've been an ICU nurse now for about two and a half years, 1 year in Medical / CICU, and now 1.5 years in CVICU, and I find that I freeze during critical situations or codes. I'm feeling discouraged because I've been doing this for two years, yet I will still find myself in this situation.

Essentially, when something happens to a patient that is an acute change, I will freeze and my mind will go blank. I think part of the reason I do this is because, not knowing what the correct action may be to take, I choose to not act as opposed to doing something that would harm my patient or be incorrect. Ultimately, I don't want to make a mistake that would hurt someone. After talking to my charge nurse about it, she reminded me that it takes time and for some people, it takes them longer than others, and it's a matter of experience. That was reassuring to a point, but I don't really know what else to do. I would think that, at this point in my career, I would be at a point where I no longer do this, and I don't know how to fix it.

There are some situations where I know exactly what to do, because I've been through them before, but when things happen to me that I've never encountered or seen, I lock up and freeze. Any advice?

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What are some examples of times you have frozen up?

I think ACLS is every ICU nurses best friend. It's one thing to be certified, it's another thing to be confident with it. Then you have a starting point for action in any situation. Even if you don't end up following the algorithms exactly, it gets you asking the right questions.

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Rory Miller writes in his book called Facing Violence: Preparing for the Unexpected about glitches. Rory Miller is a former corrections officer and jack of all trades who writes extensively about self defense principles that can be easily applied to any walk of life (such as medicine). Two things that he discusses are glitches and the OODA loop (Observe, Orient, Decide, Act). If people freeze, it is generally because of a combination of those two factors. Glitches occur for various reasons (Miller talked about one developing for him because he didn't have life insurance; once he got that, he was no longer thinking about his children and family during a violent encounter with inmates, and the developing glitch was diffused), and can occur in anyone at anytime. A good way to fix glitches is to examine why you freeze to begin with; is it because you over analyze when you should fix what you can at that time? Is it because your past encounters with failure are interfering in your present trust in your skills? That is for you to examine on your own and come to an understanding on why you freeze. You say that it is a fear of harming patients, but is that because you don't trust your skills and education? You could precept new RNs, that would very clearly show you where you are strong and where you need work. You could also imagine these disaster scenarios and think about what you would do. In my spare moments working the ambulance, I like to think about my stable patient suddenly crashing on me. What do I do first? What is next? What do I tell my partner who is driving? I picture myself performing the physical actions of cutting the shirt, placing the pads on, turning on the defibrillator, beginning compressions, and everything else that goes with that particular scenario. That way it feels like I've already done it before.

Another aspect is the OODA loop, which stands for Observe, Orient, Decide and Act. Sometimes, your brain gets stuck on the observe and orient part, and you are unable to Decide and Act. This can happen for a few reasons. The fix for this, generally speaking, is to go back to basics. I've frozen multiple times in my short EMS/RN career. Several times I've encountered situations that are just so foreign that I don't know how to handle it. What I do is tell myself that I'm frozen, that I have to do something, and remind myself of ABCs, quite literally. Is there a patent airway? Are they breathing? Is there a pulse? If I can answer those questions, I know I have some discretionary time to think. If I can't, I have to fix what is broken. I think that any action that attempts to correct an ABC is not going to harm the patient, even if it may not be the best one. It is simplistic, especially considering you work in an ICU, but starting from the ground up gives traction and allows you to clearly assess the situation. If you have a minute, you should buy his book and read it. It is mainly about understanding the dynamics of self defense, but much of it can be applied to daily life. Just my $0.02.

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When I was in the ICU and when I am in the OR now (in CRNA school) I think "what is the worst thing that could happen to my patient right now?". For instance, in a simple laparoscopic abdominal surgery, I imagine that that surgeon punctures the aorta (or the patient codes, or the ET tube gets pulled out... whatever). I then mentally go through the step I would take. The key to this is not to just breeze through and say "oh I would start giving blood with the rapid infuser", mentally go through each step in priming the blood tubing, setting up the infuser, getting central access, etc. if you do this, when things go wrong it won't be "a situation I'be never encountered" because you will have already worked through the steps. It would be extremely unlikely for a surgeon to ever puncture and aorta like I gave as an example, but if they ever do I will have run that simulation in my head and will be a few steps ahead.

Next shift you are recovering a heart, just say "what would I do if the patient went into tamponade?" Call for help, make sure chest tubes are draining, call surgeon, go up on epi drip, get chest cart to bedside in preparation to open, etc. Work through these situations and you will be better prepared for when it goes down for real.

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Specializes in CVICU, MICU, Burn ICU.
When I was in the ICU and when I am in the OR now (in CRNA school) I think "what is the worst thing that could happen to my patient right now?". For instance, in a simple laparoscopic abdominal surgery, I imagine that that surgeon punctures the aorta (or the patient codes, or the ET tube gets pulled out... whatever). I then mentally go through the step I would take. The key to this is not to just breeze through and say "oh I would start giving blood with the rapid infuser", mentally go through each step in priming the blood tubing, setting up the infuser, getting central access, etc. if you do this, when things go wrong it won't be "a situation I'be never encountered" because you will have already worked through the steps. It would be extremely unlikely for a surgeon to ever puncture and aorta like I gave as an example, but if they ever do I will have run that simulation in my head and will be a few steps ahead.

Next shift you are recovering a heart, just say "what would I do if the patient went into tamponade?" Call for help, make sure chest tubes are draining, call surgeon, go up on epi drip, get chest cart to bedside in preparation to open, etc. Work through these situations and you will be better prepared for when it goes down for real.

Excellent advice on how to practice critical thinking!! Love it!! I will be using this language with new nurses.

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Specializes in ICU.
What are some examples of times you have frozen up?

I think ACLS is every ICU nurses best friend. It's one thing to be certified, it's another thing to be confident with it. Then you have a starting point for action in any situation. Even if you don't end up following the algorithms exactly, it gets you asking the right questions.

Actually I would go back to BLS- do I have an airway? Is he/she breathing? do I have a pulse/perfusion? if the answer to those questions is yes, you can take a breath, relax, and THINK

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Nurses who feel inexperienced or anxious in emergencies often avoid them when their coworkers are experiencing an emergency. This is very unfortunate. I strongly recommend going out of your way to help out your colleagues when they are in critical situations. You're not looking to take over the situation for them - just be present and find a way to be useful: get in line to do chest compressions on a coding patient, or stand in the doorway ready to go grab more supplies as they are needed, or offer to be the designated recorder during a code.

There are two huge upsides to doing this:

- Your colleagues will be more likely/happy to help you out in emergencies.

- You get used to emergencies without feeling the pressure of having it be YOUR emergency to manage. It helps you learn what to do and what to look out for. It gets you used to emergencies so that you aren't freezing or panicky during your own.

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