Calm vs. Panic in a Crisis: What Makes the Difference?

Dealing with crisis is an inescapable part of being an anesthesiologist. Quick thinking, composure, and focused execution in a high-stakes situation under intense time pressure—we’re all familiar with it. Over the years, I’ve observed two types of anesthesiologists in a crisis: one is composed and cool like a cucumber, and the second type is panicked and red like a chili pepper. What separates the two? Why are some people better at staying calm in the middle of chaos?

I’ve seen many crises during my 20 years as an anesthesiologist—I’ve managed my share, and I’ve witnessed others managing them. Here are some of the adventures I’ve had: aortic annulus rupture after TAVR valve deployment (three times), laser lead extraction that resulted in SVC rupture (twice), numerous trauma cases for penetrating injury, unexpected difficult airways, and many more. I’ve given a lot of thought to the question of what makes someone calm under pressure. Here’s my take. 

Competence

I think the main factor is simply being good at your job. An anesthesiologist has to anticipate, prepare, and execute the mental and physical elements of the job. Whether by training or by instinct, some people are better than others at foreseeing problems and handling them when they arise. But consider this: most emergencies in anesthesiology —massive hemorrhage and resuscitation, airway emergencies, and hemodynamic instability—shouldn’t be unfamiliar to a properly trained, competent anesthesiologist. So, if you know what you’re doing, there’s no need to scream, shout, and throw things—these actions only distract from the task—you simply go about executing the tasks that need to be done. Panicking and acting out may simply reflect a provider’s lack of confidence in their skills. 

Being comfortable and adaptable in fluid, unpredictable situations

We’ve all been in situations where something bad is happening, but there isn’t a clear explanation as to why it’s happening. Is the patient in DIC? Are they in heart failure? Is this an allergic reaction? Is this patient’s throat swelling going to get worse? People who don’t like uncertainty are very uncomfortable in these situations, and this causes them to be stressed out and jittery. Why do some people do better with uncertainty? They declutter their mind, focus on the known facts, and continually adapt themselves to new data points. Adaptability and flexibility in real time — this is the secret sauce.

Experience with high-pressure decision-making in non-medical settings

High-risk activities such as skydiving, piloting, scuba diving, or mountain climbing involve high-stakes decision-making under time pressure. Someone who enjoys these hobbies is already familiar with hairy situations, so it stands to reason that that familiarity carries over to their job as an anesthesiologist. They know that panicking in an emergency is detrimental to successful resolution. 

Situational awareness 

Anesthesia emergencies require immediate judgement and action, but rarely are they entirely unexpected. Not all anesthesiologists are built the same: some are fully engaged in their case and the environment around them, while other anesthesiologists set the sevo to 2% and resume day trading on their phone. A good anesthesiologist has already considered the possible worst-case scenarios and has prepared contingency plans, while an average anesthesiologist is preoccupied with chatting up the attractive new OR nurse. Most anesthesia emergencies are scenarios that we are trained to handle—airway, hemorrhage, codes, and resuscitation—but being fully engaged and situationally aware is part of that “something extra” that separates the great from the merely competent.

Experience

Back when I was a cocky young man, I had a saying: “I’ll take talent over experience”. But 17 years of clinical practice have taught me that talent plus experience is the final boss — the best of both worlds. Like I mentioned before, I’ve participated in multiple crises in my career, but more importantly, I’ve been through the same crisis multiple times, and I found it easier to deal with the situation on the second and third go compared to the very first time. Pretty self-evident.  

So, being calm in a crisis occurs through a confluence of various factors, most of which can be gained through competence, situational awareness, and adaptability. Of course, there’s always an “unteachable” aspect; some people have a calmer disposition by nature, but I think this is a minor factor. Keeping calm in a crisis will take you from good to great!