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Bouncing Back

Racing from Tragedy to Tragedy without Reflection Could Be Source of Burnout in EPs

Patitsas, Peter, MD

Emergency Medicine News: May 2019 - Volume 41 - Issue 5 - p 26
doi: 10.1097/01.EEM.0000558191.84488.77
Bouncing Back

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Every room in the emergency department holds memories. Sometimes I think about my patient encounters by standing alone in an exam room. Each one holds a story worth hearing, sharing, and caring about. If only there were time to honor it.

Physicians have a high rate of burnout despite the variety, meaning, and reward the profession offers. If you are in a room with 10 EPs, chances are six of them are burned out; some may even be considering not going back to work. (AMA. Jan. 31, 2017; http://bit.ly/2sDMgzG.)

We often don't recover from burnout. An analysis presented at the American Psychiatric Association annual meeting last year showed that physicians die of suicide at twice the rate of the public, with one doctor dying of suicide every other day. (WebMD. May 8, 2018; https://wb.md/2sHBB6Z.)

The greatest rewards of EM are the patients and their stories. Burnout exists because we extinguish those stories from our memories as we rush from one case to the next. We don't take the time to pause and reflect on all that has been done, so we forget, and that creates dissonance. Pausing gives us a chance to recognize and be grateful for our experiences, creating lasting meaning. If there is no time to pause and reflect on what happened, did anything meaningful occur? The greater the reflection, the greater the impact of that moment's memory on our souls, like a recent case I was on.

I had just started my second year and, with it, had the added duty of going to the trauma bay. A trauma 1 alert was called. All we knew was that a truck driver in his early 40s without a pulse would arrive in 12 minutes. I went straight to the trauma bay, suited up, and took a spot at the foot of the bed. I imagined myself assisting with compressions or placing an intraosseous line if IV access were difficult. I was ready to help, but uncertain of what would be required of me.

The patient arrived. EMS was doing compressions as the stretcher came through the doors. As soon as the patient was transferred to the trauma bed, everything began to move fast.

The best of Western medicine was provided that day. The patient was intubated and had bilateral chest tubes placed to drain a liter of blood from each side. IV access and bilateral intraosseous lines were obtained. Liters of saline and numerous units of blood and platelets were transfused. Epinephrine was given while compressions continued. Even emergency pericardiocentesis was performed. Thirty or so health care workers gave their best. But by the 25th minute, the attending physicians began to exchange glances. By all protocols and experience, there was no use in allocating more resources. It was time to move on, time to take care of others. Time of death was called, gowns and gloves were removed. I took off my cap and mask. I approached the patient, dead in the trauma bed, and blessed him. I took a deep breath, and disposed of my gown.

Did we perform tasks that day? Yes. Did we execute them with skill and strategy? Yes. Did we try to save a man who was a son, a grandson, a husband, and a father? Yes. We fought but lost. It was a valiant effort, an honest effort.

As I walked down the hall, I saw the faces of people who had been in the trauma bay earlier, but they looked right through me. I looked for a glance or a nod that something extraordinary had just happened, but they were already on to the next task. I felt invisible.

As with sports, win or lose, there is something to be proud of, something worth remembering. What had happened in that trauma bay was tragic, but the efforts to bring this patient back were truly herculean. The average human being may have a few of these types of memories over a lifetime. That number may be reached in a day, though, for an EP. These tragedies can bring despair, but they also provide an opportunity for reflection, which is essential in the search for meaning.

The decision to pause and reflect on these experiences can be accomplished if we just recognized it as a priority. This is different from a debrief. Enough with optimization and feedback, how about honoring human emotion and experience as a team? Instead, we are asked to assess, perform, and move on to the next patient.

I am reminded of a study that looked at how abuse and neglect can cause mental and physical illnesses in children. (Am J Prev Med 1998;14[4]:245.) Likewise, the traumatic experiences we witness can take a negative toll on our lives. This could explain burnout among physicians. We are all suffering from emotional neglect or PTSD as we go through tragedy after tragedy and never get the time and support to build each other back up. We need time to think, reflect, express ourselves, and reinterpret information in a way that makes us stronger.

The opportunity to pause and reflect on what has happened is a basic human need. Just a minute to shake hands, nod, or even embrace all of those involved, a moment to affirm what happened, to see that everyone played a part in something worthwhile and meaningful. If we pause for a moment with each case, we will become deeper souls able to feel gratitude and see meaning in our work. We will become aware of our purpose, and that will keep us alive in our professional and personal lives. This purpose is a fire that can never burn out.

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Dr. Patitsasis a second-year emergency medicine resident at Geisinger Medical Center in Danville, PA. He founded an international nonprofit charitable organization known as St. Paul's Fellowship of Labor, which recruits volunteers to travel to Greek Orthodox Monasteries and Convents to complete labor-intensive service projects in seven countries. Find his health, wellness, and medicine YouTube channel athttp://bit.ly/2DhlbZr.

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