The Importance of Imperturbability

Sir William Osler described imperturbability as “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgement in moments of grave peril, immobility, impassiveness.” He declared the physician who is misfortunate enough to be without imperturbability, “who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients” (Aequanimitas: with other addresses to medical students, nurses and practitioners of medicine.1920).

The practice of anesthesiology is occasionally marked by the unexpected, such as hemorrhage, arrythmias, and embolic events. The startle response that occurs can result in the delay of appropriate action or the initiation of inappropriate action (asamonitor.pub/3YC78aP). Confusion can be compounded when users are not familiar with the function of the equipment they’re using or when it is poorly integrated with the user’s experience or expectations (asamonitor.pub/3LWu7pv; asamonitor.pub/3SDDf60).

The adaptive reaction to unplanned emergencies consists of the fight, flight, or freeze response. Hyperarousal can lead to tunnel vision, tunnel hearing, loss of accurate time perception, and regression to nonprofessional behaviors, such as yelling and panicking (Code Calm on the Streets. 2012). If this occurs, it inhibits the leader’s ability to manage the situation and impedes the psychological safety of the team, dissuading members from speaking up with ideas and suggestions (asamonitor.pub/3WToWwG). This behavior hinders the deliberative, creative, and collaborative approach required to successfully navigate the unexpected situation (Wiring the Winning Organization. 2023). Indeed, lack of imperturbability also rapidly loses the confidence of the team.

Actions that support imperturbability include:

• Preparation
  • Providing excellent care begins with taking care of ourselves. Anesthesia professionals who are hungry, dehydrated, tired, or otherwise unwell have decreased capacity to handle the unexpected (The Emergency Mind. 2021). ASA offers a number of resources: asahq.org/advocating-for-you/well-being.
  • Practice. The response to crisis events can be rehearsed with high-fidelity simulation, but case-based discussions and mental rehearsals are more readily available and quite effective (Acad Emerg Med 2007;14:130-7; asamonitor.pub/4fE6Shu). There is no substitute for familiarizing yourself with the function of the anesthesia equipment you use and the meanings of the various monitor warnings and alarms.
  • Plan for the unanticipated. Not every case will require multiple I.V.s, invasive monitoring, or blood products, but if you needed these suddenly in the middle of the case, what would your plan be to obtain them? Recognize that this might vary depending on the resources available at the time the case is occurring.
• Acute response
  • Control your breathing. Combat tactical breathing is frequently used by the military and athletes to mitigate hyperarousal, stimulate parasympathetic activity, and help regain focus (see Figure) (asamonitor.pub/46TH8tP).
  • Call for help. Assistance from others can introduce an “outside” view of the situation, often by those without personal involvement in the event; but their views, especially dissenting ones, need to be invited and welcomed (The Emergency Mind. 2021; ASA Monitor 2023;87:34).
  • Use cognitive aids, such as crisis manuals. They can be essential for remembering the steps and sequence of a task, but the user must already be skilled and experienced in the task itself (BMJ Qual Saf 2015;24:545-9).
• Recovery
  • One of the essential keys to maintaining imperturbability is adequate recovery (The Emergency Mind. 2021). After experiencing challenging circumstances, support needs to be readily available (Jt Comm J Qual Patient Saf 2010;36:233-40; ASA Monitor 2022;86:12; asamonitor.pub/3AeYuFf).

In addition to knowledge and experience in the field of anesthesiology, following the tips provided above can help the anesthesia professional achieve imperturbability when the unexpected happens.