The Sacred Space

Being in the presence of death is powerful.  It is a sacred thing to be at someone's side when their life comes to an end.  To be there in that moment is a great responsibility and honor.  It happens so often in the course of work in the ER.  But it is difficult to pause and be present in that moment.  It is difficult to "force time" as my mentor suggests.  Force time to slow down and be human for a moment before entering into the fast lane of the ER again.

Today was a tough day.  A young man lost his life in a horrific and sudden fire. We were there at the end of his life. In one moment we're following the ACLS algorithm, discussing options and performing tasks.  The room is calm but the activity is frenetic. Clinicians are finding IV access, performing chest compressions, checking for a pulse, intubating.  When it's apparent that resuscitation efforts are futile, everything just stops.  Time is elongated.   It feels like time has one pace in that room and another pace in the hallway outside.  

In the code room everything goes quiet. It's calm, almost silent.  People often crack a joke to let off the tension. Those who were performing chest compressions catch their breath.  There is always this moment where nobody quite knows what to do or what to say.  

Today I tried.  I tried to implement a debriefing but I realized I am woefully unprepared.  I just paused and asked everyone how they were.  We talked about how this is really tragic and really hard to see.  I explained to my very young students that they would probably cry tonight, or tomorrow.  Sometimes these things creep back into your mind when you least expect them.  It is OK to be human, it's OK to feel overwhelmed.  My most experienced nurses said it was the worst thing they'd ever seen.  The grief was real.  We paused. 

As we open the door from this sacred place to the hallway of the ER outside, it feels like accidentally walking onto a freeway.  Somehow it feels noisier and more cluttered and banal.  It is difficult to step out of that room and face the responsibilities that keep coming in the rest of the department.  Everyone seems to know how important it is to keep the door to that room shut.  We implicitly know how important it is to preserve the sacred space from the chaos of the living.  

I wish I had paused a little longer.  I wish I had invited my staff and students to be quiet in that place, or pray, or cry if even for just a moment. Soon the family will come in and we will hear their tears.  It is their grief now.  But for that moment, it is just him and those of us who tried to save him.  We stand quietly with him.  We were comrades in this fight for life.  

I was reminded of the time Jesus went to see his friend Lazarus who had just died.  The family had begged him to come and heal Lazarus sooner but He did not.  (Why He didn't come sooner is a question for another time).  Jesus knew He was going to raise Lazarus from the dead.  He was going to raise him from the dead that very day.  But He stopped when He met with the family.  He witnessed their grief and He grieved with them.   "Mary said to Him, 'Lord, if You had been here, my brother would not have died.' When Jesus therefore saw her weeping, and the Jews who came with her also weeping, He was deeply moved in His spirit and was troubled, and said, 'Where have you laid him?' They said to Him, 'Lord, come and see.' Jesus wept."

To be in the presence of grief and death and feel "moved" is to be human.  To enter into that place of shared experience with our fellow humans is powerful and real.  It is good to pause and feel the weight of grief and loss.  It is healthier to force time and let that experience be strong and engage it face to face than to ignore it and pretend we feel nothing.  

"Suppressed grief suffocates, it rages within the breast, and is forced to multiply its strength." - Ovid

We cannot and should not grieve like the family of the patient, but we should grieve. We all grieve this moment in our own way.  It cannot and should not last long.  ER people are experts at putting things behind them and moving on.  But grief that is not recognized tends to show up in strange ways.  We see the news story that night and it all comes back.  I play with my kids and have a moment of fear about all the terrible ways people can be injured.  I cry at a beautiful piece of music and find myself thinking of that case.  Or worse, we build walls that separate us from our own sadness and stress and we become less human.  In separating ourselves from this grief, we will separate ourselves from others.  If we think we can just walk out of that room and never deal with the trauma we witnessed, we are fooling ourselves.

It is good to pause.  It is good to stand and be present in that sacred space.  It is good to be human.

 

Heroin - Part 2

This may sound familiar to my prior post for July.  It is.  Every encounter with a heroin overdose is the same.  Someone drops off somebody else who is "not breathing and turning blue".  They are crying and scared to death.  The user is indeed, limp, head rolling around, with agonal respirations and cyanosis around the lips.  We glove up, run out to the driveway, and dead lift the individual into a wheelchair.

We administer naloxone and magically the person wakes up.  They usually wake up angry.  They can even be angry that we treated them and ended the high. Once, after I had bagged a 23 yr old for two minutes until the naloxone took effect, the guy wakes up, looks me dead in the eye and said,

"I hope you didn't give me that damn narcan".  

His sister who brought him in yelled at him from the foot of the bed and said, "Yes they did! You were dead!". 

It was only 5 days until I was involved with another heroin incident.  A car whips around the ER entrance and a woman frantically gets out saying her boyfriend isn't breathing.  A 10 month old is sound asleep in the back seat.  Next to the baby is a 3 yr old girl with giant eyes and tears streaming down her cheeks.  She is frozen in fear.  Her tears are silent. In the front seat is a twenty something man barely breathing.  We shake him and he starts to come around but he is altered, weak, and very unsteady.

"I'm fine.  Leave me alone.  Take me home".  He starts yelling at the girlfriend that it's not big deal and she should have never brought him here.  She is terrified to get back in the car with him.  Now we have a medical-legal pickle.  There are young children in the back seat with an altered and potentially dangerous "father" in the front seat.  The mom is actually pretty decent.  She is very worried about the safety of her children but equally worried that if she leaves the guy he will head back to his drug friends and will certainly overdose there.  The user is refusing care.  Mom seems reasonable so we don't really have grounds to call CPS and she does not want the police notified and will not file a report.  Hmmm.  Now what.  

At one point the guy gathered himself enough to actually get into the driver's seat.  Security stepped in and the girlfriend grabbed the keys out of the ignition.  I made a move for the baby just in case.  They got the keys in time.  Thankfully, the mom's concern for her children won out and she left the guy on the curb.  I had told her that if the four of them were in the vehicle together, the police would be immediately notified.  He staggered away.

The look of that little girl's eyes haunts me.  I have seen all kinds of trauma but emotional trauma being inflicted on a small child is gut wrenching.  They're too little to do anything but trust the grown ups in the room to fix it.  Her grown ups were a disaster.  The ER grown ups had their hands tied.  I had trouble concentrating for a few hours.  Did we make the right choice?  When will this epidemic end?  How do we help these people?  Why should we even try?  

 I started heading deep into the dark place of hopelessness.  I began working feverishly on my emotional wall, grabbing every brick of depersonalization and emotional protection that I could find.  It is too hard to care about these people.  They inflict so much pain and injury.  Why should we even try to help.  But, the ER never sleeps and patients keep coming in.  Four hours into this same shift I was suturing a facial laceration of a twenty something man.  

"How did you cut your lip?" I ask.

"I am a group leader for recovering opiate addicts and I was tossing logs to start a campfire" he said.  "I'm a recovering opiate addict and I"ve been clean for almost a year.  Now I am also a counselor at the long term recovery house that I went through".

That was a ramming rod through my carefully constructed emotional wall.  This guy was kind, sensitive, and open.  He was brave enough to share his story with me.  He had started on the journey to wellness and had turned right around to help people behind him.  I shared with him a quote that I love by Brennan Manning.  "In love's service, only wounded soldiers can serve".  I encouraged him to keep being brave because people who have been healed have the loudest voice in the lives of people who are broken.

Damn it!  I wanted to stay mad.  I wanted to build my wall, harden my heart, and not be touched by this stupid epidemic anymore.  I wanted it to be OK to hate these people and the enablers in their lives.  Putting people in boxes and building walls just doesn't work when you are face to face with a fellow human being.  When the epidemic becomes a person, compassion overtakes judgement.  Love Always Wins.

The following is a passage from Brennan Manning's work, Abba's Child: The Cry of the Heart for Intimate Belonging

“Thornton Wilder’s one-act play “The Angel That Troubled the Waters,” based on John 5:1-4, dramatizes the power of the pool of Bethesda to heal whenever an angel stirred its waters. A physician comes periodically to the pool hoping to be the first in line and longing to be healed of his melancholy. The angel finally appears but blocks the physician just as he is ready to step into the water. The angel tells the physician to draw back, for this moment is not for him. The physician pleads for help in a broken voice, but the angel insists that healing is not intended for him. The dialogue continues—and then comes the prophetic word from the angel: “Without your wounds where would your power be? It is your melancholy that makes your low voice tremble into the hearts of men and women. The very angels themselves cannot persuade the wretched and blundering children on earth as can one human being broken on the wheels of living. In Love’s service, only wounded soldiers can serve. Physician, draw back.” Later, the man who enters the pool first and is healed rejoices in his good fortune and turning to the physician says: “Please come with me. It is only an hour to my home. My son is lost in dark thoughts. I do not understand him and only you have ever lifted his mood. Only an hour.… There is also my daughter: since her child died, she sits in the shadow. She will not listen to us but she will listen to you.”13 Christians who remain in hiding continue to live the lie. We deny the reality of our sin. In a futile attempt to erase our past, we deprive the community of our healing gift. If we conceal our wounds out of fear and shame, our inner darkness can neither be illuminated nor become a light for others. We cling to our bad feelings and beat ourselves with the past when what we should do is let go. As Dietrich Bonhoeffer said, guilt is an idol. But when we dare to live as forgiven men and women, we join the wounded healers and draw closer to Jesus.”

May we all find strength and bravery to open our wounds to healing.

 

 

Physician, Get Over Thyself

Most of my writings have centered around the challenges and difficulties of working in the ER.  The job is difficult.  Clinicians need support.  But I have recently been reminded of the heart of Medicine as Ministry.  We are here to care for people.  We have a calling to care for people.  That makes this difficult work more than a job.  It is ministry.

I recently finished the memoir, When Breath Becomes Air.  This is an amazing book by Paul Kalanithi.  He was a gifted and passionate neurosurgeon who died in his thirties just at the end of an intensive neurosurgery residency.  He had a passion for philosophy, understanding life and death, and caring for people.  He describes the journey from medical school into the specialty of neurosurgery.  Many of his peers began to understand the rigors of being a physician.  They desired balance between their work, family, recreation, etc.  They were grappling with how much of their lives to give away to medicine.  The oath that they would take at graduation from Yale medical school included phrasing that they would put the patients' interests above their own.  Some wanted to remove this statement.   Dr. Kalanithi writes, 

"The rest of us didn't allow this discussion to continue for long.  The words stayed.  This kind of egotism struck me as antithetical to medicine and, it should be noted, entirely reasonable. Indeed, this is how 99 percent of people select their jobs: pay, work environment, hours. But that's the point.  Putting lifestyle first is how you find a job - not a calling" - When Breath Becomes Air, 68-69.

That served as a firm reminder that what we do in medicine feels hard because it is hard.  And yet, we have a calling to enter into this work with a different expectation for ourselves.  We should expect that this job will demand more of our time, more of our mental and physical energy than most other careers.  We must remember that working to meet the needs of others is a calling, not a job.

I will add that balance is important.  To sustain this work for long, we must figure out a way to care for ourselves and to find rest, reflection, and time with friends and family.  But Dr. Kalanithi is right.  We didn't sign up for a job so we could punch a clock, be home every night for dinner, or take a lunch break every day.  We have a calling to something greater and that carries a high price for us.

As I read the inspiring and sad story of Dr. Kalanithi I kept wishing that I could have known him.  I was saddened that this brilliant and seemingly very kind surgeon who had so much potential to contribute to our world, left us so soon.  I suspect he was funny and intense but given all of my insecurities I would have been intimidated as hell to meet him.  I am thankful for his bravery and honesty both in the struggle of medicine and in the struggle of death.  I will add him to my list of heroes and learn from his example.

(In medicine) "What had not changed...was the heroic spirit of responsibility amid blood and failure.  This struck me as the true image of a doctor."

- When Breath Becomes Air

 

 

 

 

 

 

She Was Fourteen

I was working an evening shift in the express care of the emergency department a few weeks ago.  A fourteen year girl was swept into a room with another child and an adult who could not get off her cell phone.  I was told the chief complaint was "medical clearance".  When I asked where she was being medically cleared to go exactly, the answer was, "I think she's going to a group home".

"Do you know where, or what her medical concerns might be?" 

"No. Not exactly.  I'm not her mom, I'm a wrap around worker from the County". 

Hmm.  No parent, no known medical history, being cleared for an unknown destination.  And we're in express care where patients are supposed to move in and out quickly and relatively easily.  I blew the whistle to call a timeout.  I asked the "adult" to come into the hallway so we could talk a bit more.  She was a wrap around worker who serves as an extension for the city's social workers. She also happened to be an acquaintance of the patient because her daughter was in her class.  As it turns out, the girls is a "prostitute".  She is not cared for by her parents because she has bipolar disorder and they can no longer manage her.  She runs away.  And oh, by the way, the police picked her up four days prior at a hotel.  No one knows why she was there.  When the cops showed up she told them she had not been harmed and had not been sexually assaulted. So they let her go.  Where, you ask?  Nobody knows.  She turned up and now needs to go to a group home...again.

Case manager...STAT!!!

Let me jump to the end of the story.  Because my case manager is a superhero and incredibly well connected in the city, I found out the rest of the story.  We transferred this fourteen year old girl  to a local hospital specialized in sexual assault evaluation.  It turns out (shock and awe) that she was being trafficked for sexual exploitation at that hotel four days prior.  The cops believed a juvenile that she was "just hanging out" at a sketchy hotel because she wanted to.  She does have mental health issues and is a handful.  She is known as a "runner".  Girls who chronically leave group homes, shelters, and hospitals and return to this abusive life.  It turns out that hotel was a hub of drug and human trafficking.  It turns out the cops dropped the ball and the investigation of this girl has blown up into a huge crime ring investigation.

This case has haunted me.  I have a fourteen year old daughter.  It makes me sick to my stomach to think of the atrocities that young girl had endured in her precious fourteen years.  I wonder how we have gotten to a place where cops can see this and walk away.  How many times have I walked away?  Sometimes you just don't see things unless you're looking for them.

The words we use are powerful.  If I had called her a prostitute you might think something different about her.  You might think she just chooses that "work" because it's easy money.  You might think she's a drug addict and just wants to get high.  You might be right.  But when I tell you she has a mental health disease and she is developmentally unable to make a healthy decision for herself you might pause in your judgement.  If I mention that her pimp has threatened that she or her family will be murdered if she doesn't comply with his commands and that he has repeatedly assaulted her you might think about her differently.  

Luke 7:36-50 tells us a story just like this in the life of Jesus.  Jesus is hanging out with the church leaders, the really pretentious ones.  I always think that would have been hard enough.  But then this woman who "lived a sinful life" comes in and starts washing his feet, crying the ugly cry, and pouring perfume all over him.  Awkward.  This prostitute bursts in the room, almost certainly uninvited, and causes a scene.  Jesus explains to the socially acceptable guests that this woman who has much to be forgiven, has shown more love to him than any of these gentlemen.  And he says that her sins are forgiven.

I wish for the thousandth time that I could see people like Jesus does.  Instead of a prostitute he sees a woman who is heartbroken, lonely, used up, and afraid.  And he doesn't flinch when it gets awkward.  May we have the eyes to really see people and really hear their stories.  May we watch our words and be careful of the labels we use.  

Is she a prostitute or is she a victim?  Is there any difference?

 

 

 

 

 

 

I Can See You Now

I had the honor of caring for a woman who was 101 years old.  She was born in 1916, before most people owned a car.  She lived through the roaring twenties and WWII.  She was in her middle age during the social revolution of the 60s and 70s.  She was already a grandmother when I was born.  

There is something sacred about being in the presence of an aged one.  They are living monuments to history.  Even though I am in in my middle years, I feel like a child when I am with someone like this.  It must be strange to have someone seventy years your junior take care of you.  I feel like they are tolerating me as I learn my way through life.  It makes me feel safe.  It gives me a good perspective on life.  The problems that seem to consume my moments and days are so temporary.  Even the great movements of history seem small and fleeting.  

This kind old woman just wanted to be seen for her constipation.  Her evaluation and workup for unremarkable.  Because she had poor hearing, I had to sit close to her bed and talk loudly.  When I did this she looked up and smiled.  She patted my cheek with her hand like I was a toddler and said, "Oh, now I can see you.  You're so pretty!"  It wasn't the pretty part that got my attention.  I'm quite certain she wouldn't be a very good judge of pretty based on her eyesight.  But the words, I can see you, got my attention.  

How many times do I rush through my interactions with patients to get on to the diagnosis, treatment, and disposition.  I barely take the time to really see my patients.  I almost never let them really see me.  But this lady showed me that there is something powerful in human connection.  When we can see each other it makes us better.  We can communicate, understand, and support each other.

I would like to take more time to really see my patients.  I would like to sit with them a little longer and hear their stories.  It would probably help if I let them see me too.  I'm quite certain that there is more trust and more collaboration when patients feel like they know a little about me too.

"What lies behind us and what lies before us are tiny matters compared to what lies within us." - Ralph Waldo Emerson

 

 

Dying Inside

The ER Experience

    Working in the ER means you never know what’s going to happen on any given day.  It could be busy, slow, or weird. In the ER, you never know. Those of us who work in emergency medicine have a strange addiction to this suspense.  But this sort of unknown carries a risk.  The risk is that something terrible will happen.  And because it’s the ER, something terrible often happens. When clinicians experience death in the ER and the accompanying grief, what are they to do with it?  How do we support clinicians through these difficulties and help them stay healthy so that they have sustainable careers in caregiving?  We have to recognize that ER clinicians experience trauma regularly and we need to develop better ways to help them manage stress and grief so they can continue to practice medicine with their whole heart.  How can healthcare systems develop healthy ways to meet clinicians in these struggles and build communities that are supportive and caring?

    Over the course of my seventeen years of work in emergency medicine there are a few cases that always rise to the top of the list of my memories.  They are usually sad.  They are usually tragic.  I think this speaks to the fact that trauma imprints itself on my brain as a clinician in the moment of someone else’s tragedy. 

    The event that often comes to mind is the sudden death of a seven month old infant.  This was my first pediatric code experience.  The mother had driven the baby to the hospital and walked through the front door with a limp, breathless infant.  The triage nurse grabbed the baby from her arms and literally ran to the code room where the resuscitation effort began.  The physician stood at the head of the bed and gently but quickly gained the important history of events from the mother and prepared for intubation.  The mother stood at the side of the room with her hands on her face, staring at the baby and half concentrated on the physician’s questions.  I was a brand new nurse with only a year of ER experience.  I stood at the baby’s left side and it was my job to manage IV access.  This was, of course, impossible.  The child had been apneic (without breath) for over twenty minutes.  The only access we could obtain was an IO (intraosseous line).  This is inserted into the space just below the patella of the knee.  It sounds brutal but it is fast, relatively painless, and provides reliable access for medication and fluids used in resuscitation.  My hands shook as I inserted the line. It felt cruel and tortuous to do this to such a young baby.  I knew that the efforts were probably futile and the baby was probably dead.  We worked on the child for over an hour.  Children’s Hospital was notified of the need for emergent monitored transport to their facility.  When they arrived, we continued life saving efforts for another fifteen minutes or so until everyone was in agreement that nothing more could be done.  The child was pronounced dead at approximately two am.  

    This experience occurred over fifteen years ago.  I can remember almost every moment.  The next thing I remember is the sound of the cry coming from the mother as she learned her baby had died.  There is no sound like the cry of grief in the first moment the family is told of the death of their loved one.  It is raw, human emotion and its power strikes through the soul of everyone in the room like a shock wave.  It is profound to be in the room when a fellow human moves from life to death.  It is powerful.  It is humbling. I have to grit my teeth and swallow hard to avoid breaking down and crying.  I am always aware that life is delicate and we really aren’t guaranteed anything in this world.  It is an honor and a hardship to be at the bedside when someone passes away.  I often say a prayer over the person when everyone has left and the room is quiet.  It is strange and yet sacred to be alone with death.  

    Clinicians experience grief in the moments following the death of a patient.  But we are not supposed to express this grief.  Sometimes there is occasion to let a tear fall in sympathy with family.  But usually you get the sense that they need to be alone with one another and their lost loved one.  Besides, we’re supposed to remain strong.  We are there to present information, facts, and be objective.  We are supposed to explain the cause of death and explain all the efforts we took to save their life.  And then we are supposed to move on.  But do we move on?  Do we really just walk away from what just happened, forget about it, and never feel the consequences?

Barriers to Processing Grief

    There are a few significant barriers to effectively processing these difficult events.  Even if we wanted to express empathy and grieve along side our human brothers and sisters, there isn’t time.  The pressure and demands of the work in the ER do not stop.  In fact, usually after a resuscitative effort the work of the department has increased.  Physicians and staff are pulled into one room to focus on the critical case while the rest of the department gets backed up.  It is our job to turn down the hallway, go into the next room, and care for the next person.  Not long ago an elderly woman came in feeling quite ill.  Her course quickly became critical and she died within three hours of arrival.  I was shaken by how quickly this happened.  I took exactly one minute in the bathroom to cry and then dried my eyes and went to the waiting room to talk with the family.  I spent about ten minutes with them.  I spent another ten minutes completing paperwork and order entries.  And then I moved on to my next patient who was a two year old with a forehead laceration.  I turned on my happy, playful face and went into the room toestablish an environment of confidence and calm as we cared for her wound.  I was dying inside.

    Processing this grief can be further complicated because the grief we witness isn’t exactly our own.  It wasn’t our baby, our grandfather, our spouse.  It happened to somebody else.  But we did witness it.  We were directly involved.  To see a human being slip from life to death changes us.  It leaves a mark.  Grief work is also complicated by the fact that we had the responsibility to care for the person.  It is our job to do everything possible to save this person’s life and therefore, if they’ve died, we failed.  Or worse yet, what if a medical error led to their death?  What if we forgot something or missed a treatment option or caused the death by giving the wrong medication?  Guilt enters the picture.  And then there comes fear.  What will be the repercussions?  Will there be investigations, committee review, lawsuit?  Are we supposed to talk about these questions, doubts, and sadness?  The culture of medicine historically has been silence.  Don’t talk about it, just deal with it.  

Unhealthy Coping Mechanisms

    And people do deal with it.  Unfortunately, it’s not always healthy.  Most of my partners and the nurses I work with say that they take very little time to process the events after a patient has died.  Some will go home that night, hug their children a little tighter, and have a glass of wine before bed.  People have different coping mechanisms.  Some people go for a run or talk to their spouse.  Some people drink too much or turn to drugs for relief.  Most just shove the experience down deep in their heart and try to ignore it.  Some don’t even seem to remember the events at all.  

    But these traumatic events make their mark.  They always leave a mark.  “We find out that 36 % of the EPs (Emergency Physicians) find dealing with sudden death of a young person and traumatic accident/disease involving a young person the most traumatic experience during their work activity” Scand J Trauma Resusc Emerg Med. 2016 Apr 27;24:59.  The question I have been asking is what are we doing for the care of the souls of those present at these events?  What do we do to check in with doctors and nurses who have witnessed tragedy?  It is traumatic.  But do we talk about it?  What support is available for clinicians?  How are we supposed to deal with it? How do we maintain our humanity which requires that we be human ourselves and remain strong and decisive and unaffected by these traumatic events.  Dr. Brene Brown states “If you trade your authenticity for safety, you may experience the following: anxiety, depression, eating disorders, addiction, rage, blame, resentment, and inexplicable grief.”  So often clinicians trade their full humanity with its wounds and heartache for emotional “safety”.  

Working with the Whole Heart

    For clinicians to remain humane and do their best work, they have to come to work wholeheartedly.  “Whatever you do, work at it with all your heart, as working for the Lord, not for human masters” Colossians 3:23, NIV.  How can you continue to work with your whole heart if you have to take the broken pieces and shove them down to the bottom never to be spoken of again?  Brene Brown states, “we cannot selectively numb emotions.  When we numb the painful emotions, we also numb the positive emotions.”

    We need to start talking about the fact that we, as clinicians, experience grief and trauma too.  It isn’t to the extent that a family will experience in the moment of loss.  But it does happen a lot more frequently.  We see death and dying on a regular basis.  We try our best to intervene and save lives; but often, we fail.  People die and you can’t treat death.  But what do you do with the emotions that come along with working in these difficult situations.  How can we help clinicians process these events in an efficient and effective manner?

    I believe this starts with a deep respect for human beings as whole persons with physical, emotional, and spiritual needs.  This holistic view of humans must extend to clinicians as well as patients.  I would argue that this holistic care that so many in healthcare seek to offer must actually begin with clinicians and then flow out into patient care.  Jesus said, “A blind man cannot guide a blind man, can he?  Will they not both fall into a pit?” Luke 6:39, NAS.  How can we ask clinicians who are emotionally traumatized and struggling with burnout to care for the emotionally and physically needy?  You cannot pour from an empty cup.  Jesus also says in Luke 6:45 “the good man out of the good treasure of his heart brings forth what is good”.  Physician groups, healthcare systems, and clinical departments must be sure that the hearts of our staff are well tended and have every opportunity to bring forth good fruit.  If people are dying inside they can only bring forth rotten fruit.  They will try to cover over their pain and frustration and it will work for a season but eventually their wounds will overflow into their work. 

Debriefing

    Critical incident stress debriefing is an excellent way to open the door of communication and begin the process of coping with these difficult experiences.  “Debriefing is a form of psychological ‘first aid’ that has its origins in the military. General Marshall, chief historian of the United States Army during World War II, advocated the use of debriefing techniques and sessions on the battlefield. The sessions were intended to gather information about the fighting day, but he noticed they had a spiritually purging and morale-building effect on the troops” Emerg Med J 2008;25:328-330. 

    In the emergency department, after a code, the purpose of a critical incident stress debriefing (CISD) is to evaluate what was successful during the code as well as what needs improvement. It is designed to improve clinical outcomes and process.   It is also a meaningful way to begin the conversation about the emotional effects of the code on staff.  It is important to begin the conversation soon after the event and establish a culture where open communication from everyone is welcomed.  We have started to implement this in our facility.  Ideally this takes place within minutes of the event.  It can be done at a later date but it is difficult to gather everyone together because of scheduling challenges.  It is alsochallenging to implement because of the time and clinical demands that remain in the department immediately after a code.  Often, the care of other patients has been delayed because of the critical case.  Additionally, it takes proper training to effectively apply a CISD. It is important to investigate this intervention further because CISD establishes and supports a culture where communication about both the process improvement and the emotional health of clinicians is validated and supported.  

Mentoring relationships

    Another extremely useful tool for clinicians is the development of mentoring relationships.  Clinicians are encouraged to find people who are perhaps a little older, and definitely a little wiser who can help them navigate difficult clinical events and stressors.  “Finding a suitable mentor requires effort and persistence. Effective mentoring necessitates a certain chemistry for an appropriate interpersonal match. Prized mentors have ‘clout,’ knowledge, and interest in the mentees, and provide both professional and personal support”  Acad Med. 2003 Mar;78(3):328-34.  These mentors are available to discuss difficult events and stressors in the lives of clinicians.  They are a support when a clinician encounters a difficult case or need to process grief.  Challenges to establishing healthy mentoring relationships include difficulties in effective communication, personal differences, conflict, and lack of training in effective mentoring Acad Med. 2013 Jan;88(1):82-9.  This is such an important part of growth and development in any area of life including professional development and personal wellness in a stressful work environment.  Mentoring takes time and wisdom to implement well.  It requires both the mentor and mentee to commit themselves to the relationship.  But the value of of having a trusted advisor to counsel and encourage the clinician through difficult times cannot be overstated.

Healing the Healer’s Heart

    We have to start attending to the wounded hearts of clinicians.  People who have trained and given their life to the treatment of the sick and dying need support.  As a medical community, we need to recognize that the culture of ‘just deal with it and move on’ is crippling us.  We begin to build walls to protect these tender places in our hearts and before you know it we are jaded and emotionally disconnected from patients, coworkers, and probably even our own friends and families.  As Dr. Brene Brown states, you can’t just numb the painful emotions.  You end up working and living with only part of your heart.  I believe patients can sense this.  They know when somebody cares and when somebody doesn’t care.  We can turn into distant and unfeeling clinicians.  But we might be missing something when we think a clinician is rude or cold.  That doctor might not be indifferent, she might be hurting.  She might be protecting deep wounds of grief and sadness that have never seen the light of day. The broken heart has to be healed before it can function to its full capacity.  I’m not saying that we need to dwell in the place of grief forever.  Again, the loss of a patient is different from the loss of a loved one.  AndER people have a skill set both clinically and personally to deal with things quickly and move forward.  We wouldn’t be able to do what we do if we lingered over sadness indefinitely.  But we can’t ignore it either.  As much as we care for people and their families at the moment of their death, we need to take care of ourselves.  We need to take care of each other. 

    Hospitals have many tools that can be implemented to care for people under it’s own roof.  We have an impressive collection of clinical experts in one building.  We also employ counselors, psychologists, pastoral staff, and volunteers who can further their ministry by caring for their own.  The needs of each hospital department and clinic is unique and one size of intervention does not fit all.  The needs of nurses and physicians in an ER are incredibly different from the needs of staff on a hospice floor.  But I can guarantee you they all have needs.  It will require sensitivity and creativity and time to get to know these groups and develop relationships so that these vital conversations can begin.  Department managers and leaders need to think creatively and sensitively about ways to attend to their staff in a meaningful and supportive way.  My work in this area has led me to understand two things.  First, there is profoundbrokenness in the hearts of brilliant and caring medical clinicians.  And secondly, this work of tending to wounded hearts takes time and and it is rooted in relationship.  This work of healing must take place in and amongst people and it cannot be rushed or systemized.  It will look different in every department and every hospitalBut we must start.  We must start where we are, with what we have, and we must start now.

References

The impact of occupational hazards and traumatic events among Belgian emergency physicians.  Scand J Trauma Resusc Emerg Med. 2016 Apr 27;24:59

Brené Brown, The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are

Curr Opin Crit Care. 2013 Jun;19(3):188-94   Debriefing after resuscitation

Emerg Med J 2008;25:328-330 doi:10.1136/emj.2007.048942 Debriefing after failed paediatric resuscitation: a survey of current UK practice

Mentoring programs for physicians in academic medicine: a systematic review. Acad Med. 2013 Jul;88(7):1029-37

"Having the right chemistry": a qualitative study of mentoring in academic medicine.  Acad Med. 2003 Mar;78(3):328-34

Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers.  Acad Med. 2013 Jan;88(1):82-9.

New International Version Bible

New American Standard Bible

Reflections on Belize Mission Trip - From Foreign to Familiar

“One who really loves another is not merely moved by the desire to see him contented and healthy and prosperous in this world.  Love cannot be satisfied with anything so incomplete.  If I am to love my brother, I must somehow enter deep into the mystery of God’s love for him. I must be moved not only by human sympathy but by that divine sympathy which is revealed to us in Jesus and which enriches our own lives by the outpouring of the Holy Spirit in our hearts.  (Love) must be at the same time supernatural and concrete, practical and alive."  
-   No Man is an Island, Thomas Merton

This January I went with a team of people from my local church and coworkers to continue a partnership with a missionary couple in Belize.  The focus of the trip was to continue to develop relationships, offer a three day medical clinic, and disperse dental hygiene products.  An important area of focus was the distribution of water filters to some of the neediest residents.

But as usual, I took away much more than I left behind. I learned about love on this trip to Belize.  I encountered the passage above from Thomas Merton as I was on the plane heading down.  I knew I needed to learn about real love for people in need.  It wasn’t about pity or helping the poor or fulfilling some kind of philanthropic American dream.  It was supposed to be about connecting with people in relationship so that they become friends.  When your friend has a need, you want to meet that need.  It isn’t a burden or a philosophical construct, it is practical and it comes from deep within.

The person who became my friend this time was Rosalita (name is changed for privacy).  Rosalita is a single mom who works six days a week at a company doing shipping and ordering.  She makes about $3 US an hour.  She is also a Community Health Worker in her neighborhood.  This is a person who is trained by the government of Belize in very basic health care knowledge.  She checks blood pressures, blood sugars, answers questions about sick babies, and talks about the importance of diet and hygiene.  She coordinates with the area nurse and doctor to bring people to clinic and be sure they have their medications. She is supposed to do this in addition to her more than full time work and care of her young son and aging parents.

She is a kind and caring person who knows everything about the people she helps.  She takes off two days of work to come serve as our translator at the clinic.  She is amazing!  When we would start our evaluation by asking a patient’s chief complaint, many of our patients would just say to Rosalita, in Spanish - “you tell them what’s going on.  You know everything about it.”  And she did.  She knew these people intimately and cared deeply about their needs.

I spent three days with Rosalita at the clinic.  I got to know more about her story and how her daily life works.  I truly can’t imagine doing everything she does.  I began to understand a little about her life.  She became my friend.  At the end of clinic, we went to her house to drop off some of the remaining medications and supplies so she would have tylenol and vitamins to distribute as well as supplies for diabetic checks.  We walked into her kitchen and dropped a duffle bag of supplies that basically took up half her kitchen floor.  Her whole home is probably a 12x12 concrete slab with thin walls and a tin roof.  I could tell she was a little embarrassed so we talked a little more awkwardly than normal and complimented her on her home.  We met her son and then said our goodbyes.  As we were leaving, we asked if we could pray for her.  Here she stood with four Americans in her home and she could have asked for anything.  She said, “I would like to get closer to the Lord again, I've been feeling distant lately."  And so we prayed for her.  

As we left, my heart broke. She was no longer another Spanish woman or a resident of Duck Run 3, or a Belizean.  She was my friend.  My friend has physical needs to be sure but she asked for prayer for her spiritual needs.  This was too much for my heart.  I was overwhelmed by the reality of profound poverty not as a moral or social problem but as a real way of living for my friend, Rosalita.  I was so moved because her physical needs are great but she was more aware of her spiritual need and wanted us to meet her there.  As we continue the relationships we have developed with local missionaries and friends in Belize, the most important thing we offer isn’t the stuff we bring, the money we contribute, or the healthcare we can offer.  It is the relationship we have with our friends.  Our mission is to help them do their mission.  Rosalita taught me that.

This trip to Belize offered me insight into all kinds of things.  We made great strides in strategic planning for future medical outreach and support of existing infrastructure.  We were able to help almost 100 people in the clinic.  But I hope, more than anything, we fell in love with people and that love is really what moves us forward.

“Love must be at the same time supernatural and concrete, practical and alive”. - Merton

I Got Slimed

There are encounters with patients that can make you laugh and some make you cry.  Most of the time patient encounters are polite, brief, and forgettable.  But sometimes, you get slimed.  Some patients (or staff) will suddenly dump all of their crazy right on top of your head.  Their anxiety, anger, manipulation, or stress come pouring out onto your unsuspecting little head.  It's gross.

The surprising thing about getting slimed is how it can stay with you, get inside your own psyche, and change your attitude.  I got slimed the other night.  A lady was angry that I wouldn't prescribe tylenol so she wouldn't have to pay for it.  "I have state insurance and that's what it's for so I don't have to pay!"  Her daughter sat there with a perfect weave and a NorthFace jacket and this lady was better dressed than I am most days. Then she called me a white, racist bitch and stormed out of the department.  Gross!

The interesting thing about encountering somebody's ugliness is it often digs up some of my own.  I can be arrogant.  I can be judgmental.  I can definitely be short tempered and sometimes crazy.  So, in a way, I'm thankful for her outburst.  It made me recognize that I'm not so far removed.  That crazy manipulative anger is inside me too.  

But what do you do with somebody else's junk?  A wise nurse that I work with advises, "put it in a bubble and blow it away".  Thank you, Cathy.  After lots of soul searching and processing, I think that pretty much sums it up.  Look at it, recognize it, put some boundaries on it so it doesn't infest your whole being.  And then, let it go.  

Whatever you do, don't let it get "under your skin".  That's a great saying.  These negative encounters do have a way of soaking into my my pores and contaminating my mind and spirit.  I need to take a regular spiritual shower.  If you don't shower regularly, you start to stink.  If you don't wash these ugly interactions out of your mind and spirit, your heart starts to stink.  Sadly, we can become the thing that hurt us so much.  

 

"Bear with each other and forgive one another if any of you has a grievance against someone. Forgive as the Lord forgave you." - Colossians 3:13 NIV

The Other

I am just about as white girl as a white girl can get.  I grew up in suburbs where everybody's parents went to college and they were either in real estate or engineering.  I live in a suburb where everybody is white and we all put on white button down shirts to go to work.  Everybody except me.  I get to put on scrubs and go into the "city".  I get to leave my white world and rub shoulders with a lot of different and really great people.

The issue of diversity and cultural sensitivity has been at the forefront of our national conversation these days.  It has caused me to stop a moment and think about my own perspective on myself, race, and how I treat the 'Other'.  I have to admit that my natural tendency is to clump together with people who look and act like me.  I like things neat, tidy, kind of quiet, and definitely safe.  If it were put to me, I think I would live in a bubble and never venture out.  Dealing with people can be so complicated!

But, thanks to my career path, I have been drawn out of my comfort zone for almost twenty years.  Next to EMTALA, the ER environment in urban areas is the best opportunity for character growth that I can think of.  EMTALA requires us to take care of everybody, no matter what.  Rejoice, clinicians, you don't get to pick who you take care of!  That will grow your soul.  The urban environment has a similar effect.  You get to bump shoulders with all sorts of people that don't live in your neighborhood.  I have taken care of prostitutes, homeless people, drug dealers, and murderers (that's another story).  They have all been black - and white.  I have cared for doctors, lawyers, business owners, and tradespeople.  They have all been white - and black.  I have had the honor of working with Hispanic people, Hmong people, and even some Europeans!

The really great part about working in the ER for this long is that my tendency to judge and put people into my nice, tidy, judgmental boxes has gotten a little smaller.  I have met great people who are working three jobs to care for their kids and they're doing a great job.  I have met some really wealthy people who have made me clench my fists as fast as any drug dealer.  I have learned that there really isn't the 'other'.  This idea that some people are like me and some aren't has changed.  

The people that I really have to thank are my coworkers.  People from all backgrounds who have become my teammates and my friends.  A few years ago, I might have crossed the the other side of the street if I saw some of these people coming my way.  But now, I know them.  I know their names, their kid's names, their stories about work, school, and boyfriend drama.  I know them to be good and kind and temperamental and human.  They're a lot like me.  And then again, they're nothing like me.  But in the ER, we have had to become a 'we'.  I can't work side by side with my African American coworkers and treat them with disrespect or condescension.  I need them.  We have a difficult job to do and it's impossible if it's 'us' versus 'them'.  It has to be 'WE'.  

So in all this discussion about race relations I have become even more grateful for my friends, coworkers, and patients in the ER.  They have challenged my stereotypes and preconceived notions of the 'other'.  They have taught me that when people become 'WE', we can accomplish great things.  

"God has shown me that I should not call any man unholy or unclean. That is why I came without even raising any objection when I was sent for...I most certainly understand now that God is not one to show partiality..." 
Acts 10:28b, 29,34 NASB

Patients Come Second

Working in emergency medicine is a strange place.  One minute it can feel like fighting on a battle field and the next moment it is more like serving on the mission field.  There are times of trauma, tragedy, laughter, and exhaustion.  We care for the sick and dying, the traumatized and the assaulted.  ED clinicians are expected to manage all of this with poise, empathy, integrity, decisiveness, and efficiency.  And, by the way, they can never make a mistake.  This job feels hard because it is hard.  We come home from work feeling like we got kicked in the teeth because we did.  The feelings of fatigue, anxiety, and stress are real.  This job will take every ounce of physical, mental, and spiritual ability that one can muster.

So what do we do to support our ED clinicians?  Do we give them the tools they need when they encounter difficulties.  What resources, mentoring, and guidance is available to physicians and nurses.  Where does one go when they make a mistake?  The reality is, you go to a review board, or court.  Where do you go when you work for two hours to save a kid’s life and they die.  You go home.  You just deal with it.  Who do you talk to when a patient threatens you or physically assaults you?  Nowhere.  Our hospital systems have told staff that we will not refuse care to anyone even if they have threatened or assaulted staff. 

The reality is, there is almost no support available for physicians and nurses when they encounter their own trauma in the workplace.  Our healthcare model of customer service has put so much burden on healthcare providers that it has become unreasonable and unsustainable.  Clinicians are overwhelmed by all the extra requirements of committees, JCAHO standards, documentation, and IT.  People still love what they do but they struggle to provide patient care given the ballooning workload from outside interests with no involvement in the sacred, patient-provider relationship.

Patients come second

Here's the problem.  We put patients first when they should come second.  You can’t expect human beings to function for years under this burden of responsibility with no emotional or spiritual care and not crack.  "Hospitals have missed the point that the best way to improve patient experience is to build better engagement with their employees, who will then provide better service and health care to patients. To put it another way: Patients come second.” 1

I firmly believe that if we applied focus and attention to the care of our staff they would be better equipped to provide excellent, compassionate medicine.  If the hospital organization was designed to provide for clinicians’ needs emotionally and spiritually, the staff could then give focus and energy to patients much more effectively.  If the system prioritized clinicians and what they need in staffing and supplies, they could provide care with excellence and with compassion and empathy.  But we do it backwards.  We put all the emphasis on customer service and customer perception.  

The surveys and measurements are all focused on patient satisfaction and budget concerns.  If these measurements are not satisfactory, it is the clinician’s fault.  We create more protocols and more work for clinicians in addition to an already crushing job.  You get what you measure.  If the metrics are all about patient satisfaction and efficiency, that’s all you’re going to get.  It is actually most important that we get the medicine right.  It is also important that we connect on a human level with our patients and communicate attentive presence, compassion, and empathy.  We should be measuring these things.

This means that our model of healthcare needs to change.  We need to enlarge our philosophy of medicine from simply customer service to the more accurate model of ministering healthcare.  Medicine is the ministering of care from one human to another.  In order to provide this higher level of care, we need to focus on how well our staff is supported.  We need to put resources into the well being of our staff.  

Clinicians who are cared for, supported, and resourced well will provide better patient care.2 In this extensive study at a large urban hospital, the results indicate that “hospital departments that have higher levels of employee satisfaction provide better experiences for patients.” 2 Another study found similar results.  “Patients cared for on units that nurses characterized as having adequate staff, good administrative support for nursing care, and good relations between doctors and nurses were more than twice likely as other patients to report high satisfaction with their care, and their nurses reported significantly lower burnout.”3

If we put the educational, emotional, and practical needs of our clinicians first, they will in turn provide excellent patient care.  They will have the reserves and the resources to do their very best for the people who need them.  We tell moms to be sure to take care of themselves so they can care for their kids.  We tell married couples to put their marriage first even though the demands of family are intense.  We encourage families who are providing care for loved ones to take respite for themselves.  We know that people caring for others tend to do a poor job taking care of themselves.  We need to do this for ourselves and our peers.

Steps Forward

In our emergency department we have started this conversation.  We have developed team lead meetings with nurses, MDs, and APPs who have demonstrated leadership. We meet to talk about burnout, conflict resolution, managing stress, and restoring our vision.  Leaders then communicate these concepts to the rest of the staff.  This begins to create a community of support which in turn creates a culture of excellent, compassionate care.  It’s not perfect but it is a start.  We are beginning to give voice to the clinical challenges everyone is experiencing.  No one understands how hard this job is except the dozens of people who work together every day in the ED.  We need to start turning to each other for mentoring, support, and counsel.  No one is alone in this work.  

We cannot continue to run our staff into the ground with sicker patients in communities that are crushed by chronic illness, opiate addiction, and poverty and then require more standards, more documentation, and more protocols.  We are human beings with limited capacity.  We provide care on the front lines of healthcare to the sickest and most vulnerable.  Hospital systems need to change their focus from patients first, to staff first.  If the goal is well educated, well resourced, healthy staff, the outcome will be excellent patient care with excellent patient reviews.  Let’s start measuring and evaluating these goals.  I suggest that hospitals and physician groups make a regular habit of surveying their own employees in regards to their job satisfaction.  You get what you measure. 

This is going to take some time.  But we can start this change in our own departments. Develop a culture of support.  Develop mentors and leaders.  Mentoring relationships can have a tremendous positive impact on job satisfaction.  This is an investment of time and personal commitment.  Clinicians are encouraged to find people who are perhaps a little older, and definitely a little wiser who can help them navigate difficult clinical events and stressors.  “Finding a suitable mentor requires effort and persistence. Effective mentoring necessitates a certain chemistry for an appropriate interpersonal match. Prized mentors have ‘clout,’ knowledge, and interest in the mentees, and provide both professional and personal support”.4

Make conversation about burnout and stress management common in your department.  Care for clinicians, don’t crush them.  Develop a culture of support and honesty.  Clinicians need to be able to be vulnerable with their frustrations and challenges.  Prioritize the training of mentors.  What are the real objectives of healthcare?  Don’t we really want excellent medical care with genuinely compassionate providers?  We need to consider what it is we really want from our healthcare providers.  If we only measure efficiency and customer perceptions, that is all that will ever be addressed.  We need to make room for measuring clinician and staff satisfaction.  Only by prioritizing and measuring this will we begin to focus our attention on the people who do this difficult work every day.  And if we do this diligently, patients will be treated with the respect, compassion, and efficiency that we all want to provide.

"Hospitals have missed the point that the best way to improve patient experience is to build better engagement with their employees, who will then provide better service and health care to patients. To put it another way: Patients come second."

- Patients Come Second, Spiegelman and Berrett

 

References

1Spiegelman, Berrett. Patients Come Second. New York, NY: Green Leaf Book Company;2013.

2Peltier, Dahl, Mulhern. The Relationship Between Employee Satisfaction and Hospital Patient Experience. April, 2009: http://www.info-now.com/typo3conf/ext/p2wlib/pi1/press2web/html/userimg/FORUM/Hospital%20Study%20-Relationship%20Btwn%20Emp.%20Satisfaction%20and%20Pt.%20Experiences.pdf [3/2017]

3Vahey, Aiken, Sloan, Clark, Vargas. Nurse Burnout and Patient Satisfaction. MedCare.  2004; 42(2 Suppl):1157-1166.

4Jackson, Palepu, Szalacha, Caswell, Carr, Inui. “Having the right chemistry”: A qualitative study of mentoring in academic medicine. Academic Medicine. 2003 March;78(3):328-34.

 

Stop for the One

I have been thinking and writing for a couple of years now about the struggles in emergency medicine.  I have come to realize the importance of what we do and the reality of how difficult it is.  I was at work the other day, dealing with the 5th chronic back pain of my shift, losing my cool, and feeling like everyone I meet is a loser.  I started to tell myself,  " Great concept, this medicine as ministry, but how in the hell do you keep this perspective 6 hours into a shift with difficult, demanding, sometimes crazy patients?"  How in the world do we bring the ideals of our practice into the reality of our practice.

Stop for the One.

It is overwhelming to take care of 20-30 patients in eight hours and at the same time be mindful of all these lofty but true ideas.  It's great that medicine changes lives.  It's powerful that emergency medicine is at the front lines of humanitarian needs like poverty, mental health, domestic violence.  It's true that in a given day we literally save and transform lives.  But it's also true that it can be a drag.  It can be a real drain on the soul.  

So how do we do it?  How do we allow these ideals to practically influence our work?  I have found that when I can train my brain and spirit to be present with the one patient in front of me, I can hang on to the ideal that I am ministering health to them.  I can see that one person as a human being in need.  I can care about this one.  I can't end poverty.  I don't have a solution for the desperate condition of our community's mental healthcare system.  But I am here, now, with this person.  I can't fix it all, but I can care for the one.

"Be kind and merciful. Let no one ever come to you without coming away better and happier.  Be the living expression of God's kindness: kindness in your face, kindness in your eyes, kindness in your smile, kindness in your warm greeting.  In the slums we are the light of God's kindness to the poor.  To children, to the poor, to all who suffer and are lonely, give always a happy smile - give them not only your care, but also your heart." 
- Mother Theresa

 

Heroin

Twice this week I have been working in the front hallway of our ED running the Express Care.  I hear an overhead page from triage for help to the waiting room for an unresponsive patient. We run out to the waiting room to find a triage nurse, a tech, and a security officer struggling to load an unresponsive, twenty-something, white male into a wheelchair.  His eyes are rolled back in his head, mouth gaping open, with occasional grunting respirations.  This kid is moments from death.

We know how to save this kid.  In fact, the nurse calls for narcan from the waiting room.  Get him to the back, give him narcan, save his life.  I can't speak for my coworkers, but a second thought is always in my mind as we save his life.  "You stupid kid!!  Maybe we shouldn't give him narcan and just let this whole problem end a little more quickly."

Usually within an hour the kid is completely lucid and often becomes a pain in the ass.  This particular kid started demanding food and then complained about what we gave him.  He became disruptive and verbally abusive to the nursing staff.  He ended up leaving AMA within an hour of being carried through the door, half dead.

After one episode I quickly went back to my other patients and responsibilities.  I turned around to make a plan for moving some patients with my triage nurse.  I see him leaning over the computer desk, head in his hands.  "Greg, what's going on?" I ask.  "Oh, didn't you know?  My kid overdosed last year.  I was the one who found him and started CPR.  I've seen dozens of kids like this since - this one just got to me.  I need a minute."  Everything just stopped.  We talked.  Then I left him alone to catch his breath.  I hate heroin.

My emotions are equal parts anger, frustration, sadness, and fear.  I hate this drug!  I hate what it does to people.  I feel hatred towards those who use it.  I feel hopeless and afraid.  I feel afraid of myself and how easily I become jaded. 

This is an epidemic in our country.  How did we get here?  How do we get out?  I know next to nothing of public health, AODA management, or law enforcement.  I only know emergency medicine.  I know how weird it is to save somebody's life and then immediately want to punch them in the face.  I know the grief in a parent's face that tells the story of a tragedy relived.

Where do we go from here?  I have no idea.  As clinicians we definitely need to reign in our narcotic prescribing.  We need to show young people what heroin overdose looks like.  It's really scary!  I want to tell my story and how this epidemic effects us almost daily in the ER.  I want to explain the complicated and conflicting emotions that come with caring for these people.  I want the problem to go away.  I hate heroin. 

The only way I know to search for answers is from a Christian worldview.  I hope that even if the Bible is not your language of spirituality, you will at least find some truth in the following story.

What would Jesus do?  What did he do? The story that comes to mind is the wild, demon possessed man, "a man from the tombs with an unclean spirit...and no one was able to bind him anymore, even with a chain"  Mark 5:1-17 NASB.  Scary! This guy was running around naked, living in a graveyard.  People had tried to chain him up because he was so wild.  He just broke the chains!  Jesus said, "Come out of him, you unclean spirit!".  And then Jesus asks, "What is your name?" I paused here as I read the story.  The demon answers and says "Legion, for we are many".  But I wonder if that's who Jesus was talking to.  Maybe he was actually talking to the man, not the demon. Maybe Jesus looked this pitiful, wild man in the eye and asked, "What is your name?"  This makes sense to me.  He called out to the human heart in this tormented man. 

What do we name these people?  I name them addict, idiot, stupid kid, loser.  But that's not their name.  Maybe we need to look through the crazy, manic, frightening behavior and ask people "what is your name?"

Maybe this is a way through this epidemic.  Maybe we need to look these people in the eye and ask, who are you?  Who is the real you?  What is your name? What is your real identity? Maybe they've been struggling for so long that they forgot.  Maybe we, as healthcare providers, forgot that this pain in the ass who can be frightening and disruptive, is a human being who is deeply wounded.  What is your name?  No, really, what is your name? It's not stupid kid or pain in the ass.  It's Kyle, or Demontre, or Andrea.  Real people with moms and dads, friends, kids, jobs,  and broken hearts.

I'm not saying this is easy.  Jesus was brave and bold and so tender and compassionate.  I don't feel that way in the frantic moment in the waiting room.  I want to learn this way.  Maybe, when the dust settles, getting to know this person's name will give them hope.  Maybe it will give us all hope.

 

 

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Mistakes

"There's nothing more daring that showing up, putting ourselves out there, and letting ourselves be seen." - Brene Brown

That feeling...The realization of what just happened, or what could have happened.  You get a little dizzy.  Your vision closes in on that lab result, the wrong dose, that piece of history you missed, that procedure gone wrong.  It's a little hard to breathe.  People keep talking and joking around you and you try to act like everything's fine. It happens so fast.  You're the one who screwed up.  You see it as clear as day.  You did that. How the hell did that happen?

Now there are some choices.  Forget about it! Stuff happens.  Nobody got hurt. Just move along. You can change the note a little.  Just fudge the history or the timing of events, just a little.  Or, you can blame the lab, the tech, the nurse, the secretary.  Anybody and everybody else is at fault. Or, you can own it.  Somehow you can swallow that giant lump in your throat, breathe deep, and own it.

The medical community is not so great at this.  In fact, I'm pretty sure I'm writing to an audience of one - me.  None of you have ever experienced this, I'm sure.  It feels this way.  Nobody ever talks about the errors.  I thought I was the only one until I shared it.  And then - the stories I heard made me humble, they made me cry, they made me incredibly proud to work with these people.

It made me proud of my coworkers because, to show up the day after an error,  takes some serious courage. Word travels fast, albeit, quietly in an ER. It feels like people can look straight through you.  You instantly feel vulnerable, weak, and fragile. Your confidence if rocked.  I find most people either put on an extra layer of armor and become even bigger assholes or they ignore it and act like nothing happened, hiding behind humor, grand standing, and false confidence.

What about honesty? They say it's the best policy. But man, that's tough. Unfortunately, I think it's the only healthy way through the anxiety, sleeplessness, worry, and burnout that comes from shoving these situations into the deep dark corners of our hearts.

"Here's what I think integrity is: It's choosing courage over comfort. Choosing what's right over what's fun, fast, or easy.  And practicing your values" - Brene Brown

So, that's it.  No easy answers.  No plans, policies, or get out of jail free cards.  Own your shit! The reality is, we're all humans with a whole lot of junk, faults, shortcomings, and knowledge gaps. The more honest we can be about this, the safer our patients will be.  When our medical culture changes from a bunch of islands that look perfect from a distance to a bunch of humans who communicate, ask questions, connect, and learn, our patients will benefit.  If we as clinicians can let the armor down and be more real and more honest, we will also be more free.

 For more advice on this topic read or listen to ANYTHING by Brene Brown - seriously, ANYTHING!

 

 

 

The Rewards

So much of emergency medicine is difficult.  It is busy, stressful, frustrating.  The fast pace causes us to close one case and move to the next without any time to reflect.  This morning I'm reminded of all the good things that happen in the ER.  These moments came and went so fast I barely let them register until now.  I need a dose of positive to keep me going.

Last week I had a young, nine year old boy with a eyebrow laceration.  He was a little nervous.  His dad wasn't helping.  The odor of marijuana in the room was a clue that this kid had it rough.  The next clue was when dad left the room to "make a phone call" and didn't come back for thirty minutes.  The kid said, "you can fix it while he's gone.  He makes it worse anyway".  So, I did.  Thankfully all he needed was a wound prep and some dermabond.  I talked him through the procedure as he started to tense up and whimper a little.  We sang a little song, we took deep breaths, we dreamed of big, juicy cheeseburgers.  It was over before he could be afraid.  His dad did finally come back and only said, "you didn't cry did you!"  As the little guy was leaving the department he turned around and ran back to me.  He gave me a huge hug and held my hand. 

It didn't take much, really.  He needed a calm, positive presence and reassurance.  Most families give this to their kids, but some don't.  They probably don't know how because they didn't have it either.  But in these random moments in an ER room, we can give this to a little child.  Will it change his life?  Probably not.  But he had a moment with an adult who was caring, supportive, and steady.  And this little child rewarded me with a hug that meant the world to me. 

It didn't take much, really.  I needed some positive reinforcement and reassurance that what I do can matter.  It can be a hug, a thank you, a kind word.  "That's it, you're done already? I thought that was going to be so much worse!"  Those words make me happy.  We ER people have to move so fast to the next thing that we often miss the positive.  It's there, it just takes a few minutes to remember. 

Thanks and encouragement doesn't come often.  How many codes have you been a part of when nobody says thank you? How many life saving procedures have you completed without a word of encouragement?  You can't 'expect a family in distress to remember.  Their day is way worse than ours.  Remember to give each other that word of thanks and appreciation.  We get it.  We know how hard it is to do this job well.  Be there for each other when nobody else can.

 

Truth and Love

One of the biggest problems with the customer service model is that it does not allow us to get to the root of the problems we see.  In the customer service model, the customer is always right, and they get what they paid for.  The reality is, in healthcare, the customer isn't always right.  People seek medical attention because the don't know what the problem is or how to manage it. 

Dr. Thomas A. Doyle wrote a summary of an ER shift in his blog for Emergency Physicians Monthly.  "In a single night I had patients come in for the following complaints (all brought by ambulance):  “Smoked marijuana and got dizzy”, “stung by a bee and it hurts”, “got drunk and have a hangover”, “sat out in the sun and got sunburn”, “ate Mexican food and threw up”, “picked my nose and it bled, but now it stopped”, “just had sex and want to know if I’m pregnant.” We have all had these patients.  He continues in his blog to make the point that these people don't need medical attention, they need to hear the truth that these symptoms will resolve without intervention.  They need to hear that their own actions are often causing the disease. 

This requires us to speak difficult truths to people that they will likely not want to hear.  People need to hear that weighing 250 pounds is likely causing their chronic knee and back pain.  Smoking will probably kill you it will just take some time.  If you drink too much, do drugs, engage in dangerous sexual practices, you are going to get hurt.  And it is true that behaving like you are in desperate need of narcotics often means you have a drug addiction problem.  Just because we invented illnesses like fibromyalgia doesn't mean it's real and it isn't an excuse to put everybody with depression on narcotics.  And no, vicodin isn't necessary for every dental pain, sprained ankle, and neck strain.

We have to be able to speak truth.  Truth is hard to hear.  As clinicians we have to speak this truth in love.  Being an asshole to someone who is obese, addicted, or one nugget short of a happy meal doesn't help.  We have to treat people with respect, compassion, and kindness.  Truth without love is more like a vendetta. Truth is not a license to vomit anger and frustration on someone else.  Healthcare providers need to frequently examine their own mental health to ensure we approach patients in the right attitude.

One the other hand, being loving without being truthful enables bad behavior.  Every addict has a co-dependent enabler helping them along.  When the customer services model of healthcare demands clinicians to give the consumer what they want, we are pressured to order CT scans when they aren't needed, obtain blood tests and give narcotics when we know the harm of these interventions will outweigh any benefit.  We have become the enabler.  

When we see medicine as ministry the goal of healthcare changes.  The goal is to help people be healthy and whole physically, spiritually, and mentally.  In order to be whole, we often have to do difficult things.  We have to say difficult things.  We have to confront our inner demons, start exercising, and go to a therapist.  We need the freedom as clinicians to talk about what people need, not what they want.  This may mean we have unhappy customers.  But what we're really after is healthy humans. 

Why didn't I start sooner

Do you know that feeling when someone at a party asks you to tell the "craziest thing you've ever seen in the ER"?  All of the sudden you can't remember anything.  You had a dozen stories from the day before yesterday but now everything just seems mundane and average.  Now that I have finally started to write about my journey in emergency medicine, I can't seem to recall anything interesting.

Well, now that I think about it.  There was the guy who had his penis diced up by his angry girlfriend.  When he came in for suture removal, all he could ask was, "when can I use it again?"  There was the guy found down in his backyard who had a gun in his back pocket.  We didn't realize this until after we started the code. There are the countless facial injuries and gun shot wounds from people who were, 'just minding my own business'.  And what about all the abdominal pains that are really STD checks.  That reminds me of the woman who came in for a staph infection on the inner thigh.  It was only funny when she wanted her visit billed as workman's comp because she worked as a dancer on a stripper pole.

The point is, everything we do in the ER is a story.  It's funny, tragic, frustrating, complicated.  Emergency medicine is complicated.  We love what we do!  Why else would be trudge knee deep through the muck of society's pain every day.  Our coworkers keep us going.  They keep us laughing.  Everyone needs a wheelchair derby on night shift every now and again.  Patients test our medical knowledge, our emotional fortitude, and our character.  But sometimes we meet a patient who changes our life.  Sometimes we make a difference in the world.  Sometimes we just survive ten more hours.

This blog is written to give voice to the emergency medicine clinicians who punch the clock every day and just so happen to change the world.  Most of the time we aren't even aware of it. If we were on the mission field, people would write articles about what we do.  But it feels average most days.  Well, it isn't average.  It's extraordinary.  What healthcare providers do in emergency medicine, every day, is nothing short of heroic.  

So, here's to my friends and coworkers who are also my heroes.  I am honored to be counted in your ranks.  I have admired people in the ER since I was nineteen and clueless.  I am still clueless but more aware of how amazing this job is. Thanks to all of you who show up every day.