Clinical Corner: Slow is Smooth and Smooth is Fast

by Dr. Mark Krich

I have never been in the military, let alone the Navy SEALS. But I believe the old SEALS saying – Slow is Smooth and Smooth is Fast – applies to what we do in the ER.

Wouldn’t it be great if every time a truly sick patient came into the ER, you had 30 minutes to sit and talk with the patient and really get to the bottom of the issue? Then you could do a complete head to toe assessment and evaluate for other problems the patient didn’t even know about. You could order a thorough battery of tests to prove your hypothesis as to the issue at hand. Finally, you could propose a treatment plan, initiate said plan, and craft a home regimen so that your patient will be good as new.

If you have ever worked in an ER, you are probably rolling around on the floor laughing (or at least rolling your eyes)! This might happen on an episode of House. In the real world, we have minutes (sometimes seconds) to evaluate a patient and initiate treatment.

The Critical Patient

Slow is smooth.

Do not run. Anyone who has ever worked with me in the ER knows I never run. GSW? Stab wound? STEMI? CVA? Doesn’t matter. The extra 10 seconds it takes me to get to the room is important.

Typically, you can see the patient as you are walking toward and into the room. You can see the nurses, the family members, the techs, the pharmacist. All of this gives you information. Go over the primary survey in your mind. Prepare the critical steps to the emergency airway. Walking gives you the few seconds you need to formulate your plan. Anticipate the tests you will need to order. What resources do you need? X-ray, CT, EKG, chest tube? What do you need first? Your team is skilled, but there are only so many of you. You know what needs to be done. Formulate your plan, then initiate it.

Smooth is fast.

Once you enter the room, take charge. The ER is chaotic. There is a team of people there to help. Take advantage of that! Assign roles. Your team is skilled. The team member with an assigned role will get that role done. Keep things quiet, but not silent. Communication is very important.

If you cannot hear each other, your job is that much more difficult. Odds are you are not leaving the room. Have one of your colleagues place orders in the computer for you. If there is something specific you need ordered, make sure to tell them. Don’t assume that just because you would order the test means that everyone would. Don’t be afraid to ask for help!

By the same token, if you are one of the team members and something doesn’t seem right… speak up! Nobody sees everything. There is a team for a reason.

The General Chaos

Once you get past the critical patient, you are left with “everything else.” If you are lucky, the ER is that word that rhymes with ‘glow’ that nobody is allowed to say. More likely, there are a million other things that need to get done.

Slow is smooth.

Don’t rush! You will forget things. If you forget to order the pregnancy test, and you’re waiting for the pregnancy test to order the CT, your rush just cost you considerable time. Efficiency is critical. If you have a new patient to see, get up and see them! If you are in the middle of something, finish it, but patient care cannot start until the patient is evaluated, tests are ordered, and treatments begun. The longer it takes you to see the patient, the longer it takes to get things done.

Smooth is fast.

Sometimes I tell people that I could teach my 11-year-old to do my job. I’m only half kidding! The next patient is a 50-year-old with chest pain. There is no internal struggle in my mind about whether to order an EKG, or a chest x-ray, or a troponin, etc. I do the same things on the same patients in the same way. I do not guess. My 11-year-old could do it!

I could have that internal struggle, but that is NOT smooth. Is this the case that doesn’t need the EKG? If you are having that internal debate…stop. We do things the way we do things for a reason. If you are constantly trying to talk yourself out of a test, you are going to miss things. Important things. If it takes you more than 2 seconds to decide about a test, you must order the test. Even if it turns out the test was unimportant, those are the sorts of things that will keep you up at night. “I wonder if the test would have shown…?”

The reason my 11-year-old can’t do my job? Sometimes the 50-year-old has chest pain from shingles. The EKG is probably not needed…this time. Use your brain, but don’t try to reinvent the wheel every time you see a patient. You know what needs to happen. Don’t be in a rush. Don’t cut corners. You will regret it if you do.

Smooth is fast.

Not Everything in the ER is Medical

Slow is smooth.

If you need to eat…eat! If you need to go to the bathroom…go! Rushing to see the next patient with something else on your mind is not doing them or you any favors. You need to give your patient your full attention for the few minutes you have with them.

If a patient is ready to be discharged, make it a priority. There is always someone to see or something to do. Slow down and do what needs to be done. Don’t be fast but be efficient. A discharged patient is one less patient you need to think about.

Smooth is fast.

Patients ask for things: blankets, food, drinks, a urinal, etc. My rule of thumb is that if it is going to take you longer to find someone to do the task than for you to just do the task… Do it yourself. I almost never ask someone else to do these things. We are all busy. We are a team. Be a team player! Patients absolutely notice, and appreciate, these smallest of things.

Sometimes patients or their families want to talk to you…again. “But I just came out of that room!” Doesn’t matter. They want to talk to you. You’re going to have to talk to them eventually. Maybe it’s important. Maybe they forgot to tell you something. Every once in a while, they just want to thank you! If you are in the middle of something critical, finish what you are doing. Then go see the patient. You will definitely save yourself some grief (and time) if you just go see what they want instead of postponing the inevitable.

“I’ve been waiting for hours!” We’ve all heard it… a lot. Sometimes it is true. Often it is not.

Speed on our end is not the answer. Going fast just leads to omissions and mistakes, which in the end slows everything down. Efficiency is the key, or as the SEALs would put it:

Slow is smooth and smooth is fast. Be smooth, everyone!