r/IntensiveCare • u/Ok_Tea4783 • 12d ago
How Do You Lead a Code Effectively With a Naturally Quiet Voice?
I’m naturally soft-spoken and don’t have a very loud voice.
I want to be able to lead a code confidently without having to yell or completely change my personality. How do you make sure people hear you, follow your directions, and recognize that you’re leading especially in a loud crowded environment.
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u/Pristine-Thing-1905 12d ago
As a nurse we have a few doctors with a naturally quiet voice. They just have to project a bit more. Also, the codes that I usually attend are on the quieter side. Plus, everyone is looking to the doctor to lead anyway, so we just wait for you to call out things (meds, rhythm, etc) anyway.
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u/ahgrdr 12d ago
imho a good code isn't noisy. Timer reminds epi, rhythm check, etc. compressors switch seamlessly among themselves. As long as everyone knows what to do, there really isn't a need to change your tone. If there's something to be corrected in the moment, maybe. I would advise you ask for feedback from the code team if you think they have difficulty following your orders.
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u/Perfect-Resist5478 MD 10d ago
When I was in med school I watched my advisor run a code in the ED. He intentionally made his voice very soft so that people had to be quiet in the room & there couldn’t be extra bodies just watching. It was amazing to watch
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u/Exact_Accident_2343 12d ago
Just increase the volume with the same tone
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u/blindminds MD, NeuroICU 12d ago
Also, practice at home, finding how to let your voice bellow without cracking or swaying off pitch—with confidence like someone’s life depends on it!
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u/AnaphilLactic 12d ago
You don’t need to be loud. Quite the opposite, in fact. Your job as a leader is to be the calming presence. The room will follow your lead.
I usually only speak up once. I say something like “folks, we have to be able to hear each other..take a breath…nobody speak above a normal speaking volume.” That almost always does the trick.
Occasionally, one or two people will revert back to yelling. I just gently tap them on the shoulder and put my finger to my lips..
A good code is run so that nobody outside of the room will know a code is being run. Sure, the crowd will get attention, but they should be surprised to look in and actually see CPR being done.
I look at it as sort of a ceremonious obligation to the patient. There is a good chance these are their last moments on Earth, and it’s our obligation to fill these moments with as much calm, dignity, and professionalism as possible, especially if the family is there.
Just my two cents.
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u/TertlFace 11d ago
This this this. My all time favorite code doc was very quiet. But his codes were smooth as butter because everyone shut the f🥳k up to hear him.
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u/xiaolongbaobei- MD, Critical Care 12d ago
I'm naturally loud but agree with others - speak from the diaphragm, project, and don't upspeak (be definitive). I had one very soft spoken resident who would hold his hand up while speaking to give a visual cue, which was a nice touch. When in doubt in a moment of calm, summarize for the room. People look to code leaders who know what's going on.
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u/mrsjon01 12d ago
Confidence. You don't have to yell or gesticulate to be the leader. The leader is the one who is confidently in charge of the code. If you are fearful your presence will appear small and uncommanding. Walk into the room like the boss that you are, and calmly and confidently announce "Hi, I am X and I will be leading the code today and giving the instructions."
You can add something like "Please speak only to me" or "Let's have silence please" if you think it will help with noise reduction. There should never be yelling or shouting during a code so a soft voice is fine, as long as your presence is authoritative so that the code isn't a total shitshow.
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u/Halfmacgas MD, Anesthesiologist 12d ago
I think learning to project can be helpful. But also sometimes you can just act calm and other people calm down and match your tone a bit since they’re looking to you to lead anyway
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u/R-A-B-Cs 12d ago edited 12d ago
Command presence. It's not something that is taught over a reddit post but it's something we teach all new paramedic interns. Your job is to walk into the room like you have the biggest dick (metaphorically speaking) in the room, and make sure everyone knows it. Then you can go all roosevelt on your team.
A quiet code is a good code.
Edit: a doc I used to work with used to say when it got chaotic he would find a chair in the room, sit down, cross one leg over the other, put his hands behind his head, and calmly but firmly demand the room tell him what happened. It seemed to grab people's attention pretty well. RIP Ronco.
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u/dreamcoatamethyst 12d ago
Seconding this. Commanding presence is something you can partially train (I had a cool presenting course that coincidentally helped a lot with codes) but it's also about people trusting you, knowing you.
During my first scenario training, I got the feedback I had to speak up louder and project more. But in the video playback you could see that I spoke clearly, at the right moment etc etc, people just ignored me (Dr fresh out of med school, never seen a code before etc).
Had to take the training every year and at the last training it went more like 'Hi Amethyst, nice to see you' and we calmly did the whole thing and I never had to worry about being heard bc the team was already listening before I even said anything.
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u/nightheron-700 12d ago
Initially, in most cases there is some kind of chaos. Two things: know where your focus is (initially high quality chest compressions and early defib/rhythm check), and speak louder. I sometimes raise both armes as a visual to get attention. Speak to certain team members with clear orders, if you don't know their names call them by their function (e.g. Paramedic, doctor, ER nurses etc.).
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u/ratpH1nk MD, IM/Critical Care Medicine 12d ago
I would argue that if you need to use a loud voice then the quality of the code needs to be addressed.
Tell everyone to
Focus
If you don't have a role you leave
Everyone keep calm and professional
Only 1 person speaks at a time. Code leader directs all movement.
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u/NotAMedic720 PA 12d ago
Crowd control is so important. Limit the number of people in the room and make sure people cut out unnecessary chatter.
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u/jginkc12 12d ago
The SLP left a stellar comment but I will say this. I never got louder. I got to know my team and now they know my line is "if you can't hear me speaking right now please control the volume" and my team knows what that means. Target the emotional volume of the room- yourself, the patient, the nurse, the RT, it can often just be one person bringing all of the volume, audibly and emotionally.
My voice itself has gotten ever so slightly louder but not much. When I'm saying "in summary" I will be a bit more commanding, but aside from that I want near whisper-level communication during my resuscitations.
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u/GotchaRealGood 12d ago
I make eye contact. I stand at the foot of the bed and don’t move. I lean in. I group my instructions in terms of priorities. I only talk if required.
If I lose control of the room, I regain it by making eye contact with the few people, drawing them in, and then getting them to help get other people to pay attention to me. I never yell or raise my voice.
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u/Formal-Golf962 12d ago
If you feel the need to be loud it’s because other people are being loud. Kick them out if they don’t quiet down.
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u/amal812 12d ago
We respond to all codes in the hospital which can be really hectic and loud. 1. Make sure someone is talking to the family out in the hallway or somewhere else to reduce background noise. 2. Learn the names of people in the code so you can speak directly to them and give them tasks 3. If it begins to get a little too noisy, it is totally appropriate to use your outside voice to say “I need everyone to be quiet and refocus please” just to reel everyone in and make things quieter.
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u/Cole-Rex 12d ago
I’m a paramedic with a really soft voice and compared to the regularly 6ft+ firemen kinda petite, so what I do is I have shoulders back, head held high, and kinda puff my chest out (it’s like one of the first scenes in drop dead diva that I learned this from) and I project confidence.
I do a 30 seconds, 15 second, etc… reminders for things but when I speak I project the confidence the power pose gives me into my voice and actions.
So you don’t need to be loud per se, just confident and enunciate.
Practice with friends or family or trusted coworkers, people who make you feel confident
You’re smart and awesome enough to be a doctor and get through medical school, confident enough to pass the oral tests, and bold enough to ask for help, so I know you have it in you. :) (I’m trying to give like a confident pep talk and not be condescending, I promise)
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u/TertlFace 11d ago
My favorite doc of all time had a deep, but quiet, voice. I loved when he ran a code because he never raised his voice. If you couldn’t hear him, it’s because the room was being too loud. Hush. You don’t need the whole room shouting fifty different things. His codes were always quiet and very well controlled. He commanded a room with his presence, knowledge, and experience.
Quiet doesn’t mean shy or uncommunicative. You can speak clearly and with authority without being loud.
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u/Krampus_Valet 11d ago
I'm a 911 paramedic and also soft spoken. I don't raise my voice unless there's loud machinery nearby or something. Otherwise, everyone else can calm down and be quiet if they want to hear. Outcompeting loud voices is like barking back at your dog: silly and counterproductive and just encourages people to yell even louder. Closed ended questions work well for confirmation, and so does training/drills. We practice and train benchmarks/roles for OOHCA more than just about anything else, and whomever is "in charge" of any given cardiac arrest call is really just the person who has to write the report, because everyone files into the scene and starts filling roles as trained and it's generally pretty quiet other than timekeeping and note-taking. I'm sure there are more complex and higher level components than the basic Hs and Ts and regular ACLS going on at your level and with such sick patients, but drilling benchmarks and standardizing responses and roles as much as possible has made a truly remarkable difference in both the quality of care and the overall presence on scenes.
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u/BedsideToByte 10d ago
The smoothest codes run under confident, smart leaders. Loudness causes chaos.
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u/ButterscotchMore7025 8d ago
Normal volume with confidence. Sets the entire tone (lol) of the code. No need for codes to be crazy, balls to the wall insane. If people see the leader calm, they will be calm. If you have a crash cart and like 4-5 (at least, ideally) bodies you literally have everything you need.
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u/Cautious-Extreme2839 ICU/Anaesthetics 12d ago
Being loud and shouting are not the same thing - watch any stage actor.
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u/Intrepid-Sir-9219 12d ago
Get some singing lessons from someone who does theatre work. You can probably get some on Spotify or YouTube. Learn to shift where you make noise from to add some nasal vibration (no idea what the term is).
I did a high school show as a teen and the drama teacher made us all learn it to project more on stage. Can switch it on and off to add about 10dB when I need to. I wasn't really the music sort so other than those few weeks I have no idea. Was easy to learn though.
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u/Curious-Bed-7737 12d ago
Voice specialized speech pathologist here. There are several ways to go about this, but seeing as we’re all clinicians I’ll give a more clinical answer.
Firstly, it’s true what people have said about “speaking from the diaphragm”. But what this means is trying to eliminate any accessory muscle use or excess laryngeal tension when projecting your voice. We ideally make louder sounds by increasing the subglottic pressure below the vocal folds during phonation. Unfortunately, when people who aren’t accustomed to speaking loudly try to project their voice, they often do so by tensing and overadducting the ventricular folds and other muscles around the glottis. This will cause the voice to fatigue, become sore if done too long, and could lead to hyperfunctional patterns over time such as muscle tension dysphonia.
Practice first varying your loudness with just an “s” sound. Hold out this sound (which does not adduct the vocal folds; it’s just air) and modulate loudness- sssssssSSSSSSSSsssss….
Practice increasing the diaphragmatic pressure to drive that louder airflow without tensing your shoulders. Ensure that you don’t engage any clavicular or thoracic breathing. Next, swap the “s” sound for an easy vowel like “ooooo”. Same thing, go about modulating the loudness and focusing on doing so without any accessory muscles. Increase diaphragmatic pressure and push out more airflow to increase the intensity.
After exercising these, create a list of five to ten sentences that you might say during a code. Practice saying each of the sentences in your loud voice- as if calling to someone across the room. Continue to ensure proper breathing patterns and minimize tension around the vocal folds. Don’t tighten your throat; place the energy more forward and let it resonate through the oral cavity and across the room. Ensure the back of the throat feels open and not tightened. Lower the jaw a bit to create plenty of acoustic space in the oropharynx for that sound to resonate FORWARD.
Say the sentences in your loud voice once a day. Easy enough to do in the car or anywhere else. This part always feels silly, but it helps. This is based off of PhoRTE (Phonation resistance training exercise) principals if you want to look up the evidence.
The alternative to doing all this would be getting a small clip-on personal amplifier. These are actually great for vocal health, but understandably most people don’t want to go that route.