Crozet Annals of Medicine: Pulse Check


“Can you meet me in 512?”
It was the charge nurse calling me on my work phone. 512 is our major resuscitation bay.
“Yes.” I answered her terseness with my own. By her clipped tone I knew it was something bad. I could feel my pulse rate drop dramatically as I headed in her direction. It was a well-trained response.

There is a rule in emergency medicine. When called to the bedside of any sick patient, the first thing you should do is take a pulse—your own pulse. This delaying tactic forces you to slow down, deal with your own agitation and then allows you to think carefully.

I have done this kind of work for so long that entering the room of a sick patient automatically slows my heart rate and perception of time. It is sort of the opposite of the fight or flight response and is designed to offset those panicky feelings.

I have a few techniques that allow me to function this way in high-stress situations, and I will share them with you because they work in non-medical situations too. Try these out the next time you are feeling stressed.

The first and most effective trick is to make my affect completely flat. That is to say, my face betrays no emotion whatsoever. No excitement, no worry, no anger, no fear. It is difficult to generate emotions without the corresponding facial expressions.

As far back as 1872, Charles Darwin observed, “The free expression by outward signs of an emotion intensifies it. On the other hand, the repression, as far as this is possible, of all outward signs softens our emotions. Even the simulation of an emotion tends to arouse it in our minds.”

This is now called the facial feedback hypothesis and there is some science to support it, such as experiments with women undergoing botox injections. Botox is a poison manufactured from the bacteria that causes the food-borne illness botulism. If carefully injected into the muscles of the face botox paralyzes them, which smoothes out any wrinkles associated with these muscle’s contractions. Some wrinkles around the eyes are called laugh lines and some wrinkles in the forehead are called frown lines. What researchers found is that undergoing botox injections to paralyze frowning muscles improved women’s moods. Other facial cosmetic procedures such as collagen injections did not have this same effect. Simply put, the women were unable to frown and this made them happier.

In another study, a functional neuroimaging study, researchers asked participants to imitate a frown while in an MRI scanner both before and two weeks after receiving botox injections in the forehead muscles used for frowning. During imitation of angry facial expressions, botox paralysis decreased the activation of brain regions used for emotional processing and emotional experience. Before botox injection, the patients emotional processing while frowning was much more robust and normal. An artificially flat affect decreased the human brain’s response to emotional situations.

There are many studies that come to the same conclusions. Just the act of smiling makes you happier and inhibiting a frown makes you less angry or unhappy. Professional athletes and fighters intuitively know this, and their “game faces” are usually aggressively neutral in order to remain calm while performing stressful activities.  

Another tip when facing stressful situations is to say as little as possible. This tends to settle the face and the mind. In place of words, I just stare. It is one of the perks of being a doctor that I am allowed to stare at people. Normally, it is rude, but when I stare it is diagnostic and therapeutic. My quiet quiets the room and my stare directs everyone’s attention. I think sometimes they wonder what I am looking for. Sometimes I am not sure myself. I might add an “hmmm” occasionally, just to keep the suspense high.
So, I was settled when I reached 512, just as the charge nurse was wheeling in one of the sickest patients I have ever seen. Slumped and splayed over the wheelchair with no postural tone to her muscles; she was pale and sallow at the same time, famine thin. Her lips were so dry they were pasted on to her teeth leaving her unable to close her mouth.

“I can’t tell if she is still breathing,” the room nurse announced as we moved her to the bed. She was as light as a feather.

I stared flatly at the patient. Hmmm. There was a flicker of life in her eyes. She was still breathing.

And then, with the team steadied, we went about our routine efficiently and had her stabilized in minutes. In an hour she was talking and we were formulating long-term plans with her. She looked much better. I allowed myself a smile and felt it warm me and the patient. There is a time for emotions in this job.  


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