I spent several hours behind the scenes at a big city Emergency Department. I learned a lot about stress and resilience.
WHILE PARKING MY CAR, I see two ambulances, sirens blaring, racing through rush hour traffic to where I am headed: a large, inner city hospital Emergency Department. It is 6:30 p.m. on a Monday night. Not exactly party time, but clearly, there is a lot of activity where I am going.
Three ambulances are lined up outside. Before I can get through the door, a security officer makes me empty my pockets and waves a wand over me. It is surprisingly easy to gain access to the inner sanctum from there, however, even though I have nothing to show that would legitimize my claim that I have business with my client behind those doors.
I am there to learn what the life of an Emergency Department doctor is like so that I can shape an upcoming program on resilience my partner and I will provide for them. My host is the Chairman of the Department of Emergency Medicine at a famous College of Medicine. Let’s call him Dr. Calm—because he is.
I notice a full waiting room of mostly black faces when the guard hits a button and the double doors to the doctor/patient area swing open. Behind those doors is a beehive of activity. In one small part of the cavernous facility, I count 19 people, all in some sort of uniform, moving methodically about, speaking in clipped sentences to others and then scurrying off on some task. There are beds with distressed-looking people lining the hallways; all the regular rooms were filled. Dr. Calm later says it wasn’t a particularly busy night.
Dr. Calm sees me coming and says, “Let me show you around.” He seems delighted when he encounters Rita, a housekeeper. In introducing her, he practically pays tribute to her. “Rita has been working here for a long time and we literally could not function without her.” He tells me “Rita and I have seen a lot of shit over the years. And I literally mean shit!” She good-naturedly teases him back. She’s beaming and calls him “Dr. C.” Before the tour is over, Dr. Calm makes sure I meet Masood, too, another housekeeper, the one who cleans the rooms and changes the linens. “Masood is the Einstein of making sure our beds are ready to go.” It's clear he really appreciates Masood's contribution.
We round a corner into what Dr. Calm says is the psych area. Our way is blocked by 14 police and EMT’s. (I counted.) They are surrounding a gurney with a person lying on it that I cannot see. “It’s amazing how drunk you can get with a quart of vodka,” Dr. Calm says, referring to the patient. “They’re restraining him. Let me see what’s going on.” Noticing his white coat, a few people move away to allow him access to the patient. Dr. Calm asks him his name. No response. I see the man later once he was put in a bed. He must weigh 350 pounds. There are two armed police officers milling about outside his area.
This ER has rooms for 30 patients. But the exact capacity doesn’t matter all that much; if there is a need to provide emergency care, the ER takes them even if they must lie on beds in the hallways. And, like I said, they do this night. “Some of the other ER’s in the city have a reputation of diverting patients,” Dr. Calm says, referring to the practice of refusing to receive ambulances. “We almost never divert.” I don’t ask, but I’m guessing, given the hospital’s financial difficulties, that this is partly a financial decision. More patients means more revenue. But knowing Dr. Calm, it’s also a commitment to the community.
By the time we finish the tour, Dr. Calm has been approached by three different staff with questions about patients: should I order this test? Do you agree we should ask the woman in C1 if she was drinking? Etc.
On that tour, I see one of the few white patients being wheeled down the hall. Dr. Calm asks her how she’s doing. “I’m…not…doing…very…well…,” she said, haltingly without opening her eyes. She looks like a suburban grandmother. “She collapsed at work,” Dr. Calm says. “We’re not sure yet what’s going on.”
About this time, I begin hearing a man yelling loudly and plaintively. He is lying on one of the beds in the hallway. I don’t count the times I hear him yelling over the next 30-minutes, but it must be at least 20. Always the same pattern: three cries, each escalating in volume. “Help! Help! Help!” There are frequently one or two people at the man’s bedside, but no one seems too worried about his plight. There are times when his yelling draws no attention at all. After hearing the bawling a few times, I ask Dr. Calm if it bothers him. “I’m attuned to how a true cry for help sounds,” Dr. Calm said. “In this case, notice how vigorous his yelling is. He may need help, but he’s not in physical danger.” Dr. Calm points out that an emotional response—irritation, say, or worry—won’t help under any circumstances. Referring to the guy yelling Help!, Dr. Calm says, “An emotional response won’t help him, but Haldol will.”
The doctor behind me has successfully tuned out all of the Help! yelling too (I presume this is because it wasn’t his patient to begin with). I know he’s tuned it out because he is speaking to another doctor about something cute his young daughter said to him the day before. He no sooner gets the story out than they’re both interrupted at the same time and go their separate ways.
Dr. Calm points to his computer screen and tries to explain the information system they use in this ER. I notice a list of presenting complaints listed: lacerations, chest pain, altered mental status, abdominal pain. He wants to explain how it works but keeps getting interrupted.
Part of Dr. Calm’s role on this shift is to teach residents and interns while they provide care. The interns are the ones most unsure of what tests to order and what to make of them and ask for his attention continuously. “Her sugars are down,” one says. “There are weird stools.” Nurses, too, seek his counsel. I admire Dr. Calm’s patient way of helping all of them understand the issues involved. He had earlier explained to me that there are two aspects of Emergency Medicine to get right: the technical part and the people part. “Both are critical,” Dr. Calm said, “but young physicians think only the technical part matters. And sometimes they are completely baffled by the people part.”
A woman who came in complaining of pelvic pain and missed menstrual periods is frustrating a resident. She won’t submit to a pelvic exam. Dr. Calm suspects psychiatric problems, asking the resident, “Did she seem a little odd to you?” The resident replies, “Yes, but I just thought it was a cultural thing.” “She’s psychotic,” Dr. Calm says.
Later, Dr. Calm tells me, “Most of the young docs will spend five minutes with a patient and order five or more tests. We have one very talented doc here who the younger guys make fun of at times. This guy will spend 20 minutes with the patient and order no tests at all, maybe, because he really understands what’s going on.” I asked Dr. Calm, “Doesn’t it say somewhere in your training that the doctor should ‘listen to the patient; he’s trying to tell you what’s wrong with him’?” Dr. Calm seems pleased that I know this. I looked up the quote later and found it attributed to Sir William Osler, MD, considered the father of modern medicine: “Listen to your patient, he is telling you the diagnosis.”
Speaking of that information system on Dr. Calm’s screen, I notice him squinting to see it. Looking over his shoulder, I cannot not read one word. I mention that it seems hard to read. “It is and that contributes to record-keeping errors,” he says. “These systems were built for billing purposes, not for helping patients.” As we discuss this, he describes two problems: the screen is not built with modern concepts of infographics in mind, and while entering data, the doctor is constantly interrupted. I ask what happens if he forgets to put some data in or can’t see that his small typed words contain an error. “This is why I love our nurses,” he says. I comprehended in a nanosecond how valuable teamwork in medicine is and how important it is for patient safety. One can imagine a nurse saying, “Doctor, did you really mean to order 12 injections of morphine?”
Gradually, the hubbub dies down and most of the police and EMT’s leave. You can almost hear yourself think. The Help! guy is now asleep, the Haldol having apparently kicked in. Then, the overhead loudspeaker announces an incoming trauma case. Trauma cases refer the very injured. If you’re mangled in a car accident, or have a gunshot wound, or you fall from a building and are still breathing, you’re a trauma patient. In this case, a young man had fallen on a basketball court and was unconscious, a fairly mild case as these things go. Later, his mother is relieved to hear that all will be well with her son. She seems very happy that the staff is so professional and attentive to her son. She expresses her appreciation.
Dr. Calm tells me that one of the tests on the gray haired grandma has come in: very high alcohol level. They weren’t sure at first that she’d been drinking. Is this why she’s not in the intoxication area? They discuss what to do but I can’t hear it because of the noise. I ask what the ER doctor’s responsibility is in a case like this. Treating alcoholism is surely not an ER doctor’s forte. Dr. Calm tells me that since her family is there, he’ll gather them later and have a conversation with her about what might be going on that gave rise to so much drinking—at work, no less. If there is an opening, he says, he’ll make a referral for counseling. If not, she’ll get released.
Back at his computer screen, Dr. Calm groans: the lab tests he’d ordered for a high-level official of the university were cancelled mysteriously. She’d complained of pain in a meeting and was brought to this ER. She’s crabby and wants out of there. Now he’ll have to tell her she’ll be further delayed, but he seems nonplussed.
It’s time for Dr. Calm to have his mid-shift meal. I join him in the staff break room. It’s clear by the way he’s shoveling his meal in that he can’t take too much time away from the action. The table we’re sitting at has a severe wobble. The lighting is gloomy. I’ve seen grocery store break rooms that are far more opulent. This place is all business.
I ask him if it sometimes takes a while after working in the ER to calm down. “Yes. Sometimes, after a grueling shift,” Dr. Calm tells me, “I will find myself reflecting on all the decisions I had to make one right after the other. I wonder to myself, ‘How did I make all those decisions? Were they all right?’” Almost invariably, he says, he sleeps well because he’s found over time that they were.
Dr. Calm tells me how hard it is to learn to do this job. People drawn to Emergency Medicine like the quick pace and high stakes. They’re also very smart. But none of this makes them good at a task during which you must make life and death decisions regularly with little time to contemplate. “And it’s a challenge to detect the patterns in all the various data points,” Dr. Calm says. “Many of them feel like they have to be Houdini on every shift,” he says, referring to the self-imposed need to know everything and do everything perfectly.”
I inquire further about the stress involved in the work and what it was like for him to master the craft of Emergency Medicine. He tells me about two recurring dreams he used to have in the early days. In one, he is being threatened by an attacker. He has a pistol and raises it to protect himself, but the bullets all fall out. In the other, he’s shot five times in the chest. The bullets create no entry or exist wound but he can feel them under his skin. “I haven’t had those dreams for a long time,” he says, smiling.
The stressors I noticed were legion. I’m being asked to help these doctors learn to be more resilient, so I must list them. I’m sure my list is incomplete:
- Noise (loudspeakers, Help!, equipment beeping, many people talking, patients groaning)
- Blood, vomit, and other bodily fluids are everywhere, creating an ever-present risk of personal infection
- Many of the patients are violent (or the people with them are)
- People are very sick/injured, giving rise to normal emotional reactions anyone has in the presence of human suffering
- The need for quick, continual, life and death decision making when there is insufficient data
- Shift work and the challenges to sleep and work/life balance this represents
- For residents and interns: multiply all of this by some x factor to account for the fact that no classroom experience can help you master this; you’re in the deep end every shift.
- Litigation worries
- Overwhelming paperwork
The consequences of all this, Dr. Calm tells me, is three-fold:
- Emotional and physical exhaustion
- Becoming callous and unfeeling towards others (patients and family members)
- Devaluing your own work
I look closely for work practices and social norms that seem likely to mitigate stress for staff, but I don’t find much. Maybe I just don’t know enough to look in the right places. I notice that staff are very supportive of one another. I see this in the respectful way they talk to one another, the occasional joke or friendly teasing. But those supportive interactions last no more than a minute, often less, and each person goes on quickly to attend to some responsibility.
The physicians have far more down time, it seems, than the nurses and other staff. At least it looks this way since those docs are constantly looking at computer screens. Dr. Calm spends far less time at the screen that the three docs surrounding me. I know Dr. Calm to be highly energetic, but why is he so busy when the others appear not to be?