Then, Pause and Breathe

Pausing to quiet the mind. Illustration by Dan Dworkis, MD-PhD

After a bad outcome, it is tempting to rush immediately into trying to dissect what happened and learn whatever we can from it. Maybe this is because it hurts so much and we want to do anything other than feel that hurt. Maybe we are scared it will happen again or get worse, and so we want to jump immediately to “fixing it.”

The thing is, immediately after a bad outcome, we are usually not fully ready to process it. We need to find some measure of equilibrium first. We need to pause and create space between the acute phase of our reaction and the learning and growth-focused phase which will come next.

Physiologically, our stress response — triggered in this case either by the bad outcome itself or our fear of it — involves a variety of electrical and chemical signals with far-reaching consequences in our body and our brain. To really process what happened requires our most flexible and creative modes of thinking; to bring these back online, we need to allow our physiologic signals of stress to run their course and wash out of our bodies.

Imagine there was a medication error and your patient in the ER was incorrectly given a dose of an antibiotic to which they were allergic. Unfortunately, the patient went into anaphylactic shock and required a breathing tube and intensive medications to stabilize their blood pressure. It was a difficult situation, and you are angry and upset that the error happened on your watch, and you are sad that this patient suffered something that probably did not have to happen.

In this scenario, how likely is it that you will be immediately able to perform a thoughtful analysis of the medication ordering and delivery system with enough detail to allow you to pinpoint where the error actually occurred?

Instead, your initial thoughts are probably dominated by large, blunt concepts that need to wash out before more flexible and precise thoughts can occur. So, we pause and we breathe.

Putting this idea into practice is simple and straightforward. After you identify a bad situation, just pause and take some deep breaths. If you have a favorite breathing technique, use it. Personally, I use “tactical breathing,” which is sometimes also called “box breathing.”

The shape and form of the pause should be tailored to fit the environment and available resources. After the imagined medication error for example, we might only get a few moments to regroup before the next ambulance comes in, so this pause might be short.

It is important, though, that the pause should be at least 90 seconds. Evolving understanding of how our brains process emotions (from experts like neuroscientist Jill Bolte Taylor, for example) has shown that the initial surge of chemical signaling in a strong emotional response lasts around 90 seconds. Only after that can other, different signaling processes start to take over.

If there really is not even 90 seconds to pause and allow the initial reaction to pass through — and in a crisis, there might not be — then we probably do not have the time to execute the learning/growth phase of our response either.

Instead of trying to process without first pausing, we should just use the initial step (to label it “suboptimal”) and continue doing the critical tasks that need our attention. Later, when we are in a safer and calmer space, we can try again to regroup and start actively learning.

If, however, it is the end of our shift or if a teammate can handle the next case, our pause would likely be longer and would allow us to more fully separate from the event and change our state of mind. There is no exact timeframe for “settling down”, and it might be a few hours or days before we’re really in a place to process and learn from what happened.

The idea, though, is not that we wait until we have zero emotion about an event; for the most difficult events like the loss of a loved one, that might never happen and there is nothing “wrong” or “bad” about emotion. The important part is to take enough space to allow the largest initial wave to pass through us so we can start to set the stage for deeper processing.