Communication Matters Wednesday, February 15, 2023
“Turn down the RAS”
In our brain, we have a reticular activating system (RAS) located in our brain stem which is responsible for our level of alertness.
When a person is in pain, or is afraid, or cold or is nauseated; their sympathetic system is in overdrive. Their RAS is turned way up which worsens pain, fear and nausea.
The majority of patients presenting to the ED have pain, fear, or nausea. Our first encounter and communication with all ED patients should be an attempt to turn down the RAS and increase parasympathetic activity. We must physiologically and verbally offer therapy. The majority of this therapy is immediate, very effective and non-pharmacological—though frequently not employed.
Here is how we turn down the RAS—and therefore offer effective therapy for pain, fear, coldness, and nausea:
- Turn down the lights (unless starting an IV). If you are unsure if the patient wants it darker or brighter, ask them. Just giving the patient choices, gives them some control. This alone turns down the RAS. If you have any question at how noxious fluorescent lighting is, just for grins lie down flat on a bed with all the overhead lights on. If you want it to feel like torture, put on a c-collar with the lights on.
- Get a pillow. This obviously simple answer seems to be the hardest to accomplish in our ED. If you have a headache; if you are nauseated; if you have kyphosis; if you have sinus congestion; if you are obese or have sleep apnea—lying flat on your back with a hard bed behind your head makes it much worse. After 20 years of begging for this one simple cheap, effective patient satisfier; we still have nurses and techs that are allowed by leadership to “turn over a bed” without a pillow.
- Warm blankets and warm fluids.
Being cold may be as bad as being in pain or nauseated—even more true for older
patients. Everyone should be asked if they would like a warm blanket. If they are
obviously cold, get two blankets—one one their body and one around their head!
We may not know that “room temperature” fluids are cold! Imagine swimming in a 68
degree pool. And if the fluids are on an ambulance, room temperature may be very
cold. If the fluids are normal saline, they should warmed!
4. Warm, calm, encouraging voice
Softly and confidently saying things like “We are going to get you feeling better very
soon.” ; “We are going to take great care of you.”; “You are in a safe place.” “You look
like you don’t feel well so I want to start immediately helping you with pain, nausea,
and fear—and we can talk in detail later after you feel better.”
5. Encourage the patient to breathe slowly exhaling through their nose and to imagine
their heart rate going down. Just thinking about breathing can be a good distraction. And prolonging your expiratory phase in a relaxed posture can enhance parasympathetic activity and calm your adrenergic state. If you think this is hocus-pocus “mindfulness”; consider what athletes do right before a race or a speaker before an important presentation or discussion. Or think about what all of us do after a tough physical or emotional task-we sigh deep and long—unconsciously using parasympathetic control over sympathetic surge.
These 5 easy immediate non-pharmacologic therapies communicate a place of comfort & safety that allows patients to have less pain, nausea, anxiety and discomfort.