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A Piece of My Mind
May 10, 2022

We Are Drowning

Author Affiliations
  • 1Department of Emergency Medicine, Northwestern Memorial Hospital, Chicago, Illinois
JAMA. 2022;327(18):1763-1764. doi:10.1001/jama.2022.6759

We are drowning.

“14-year-old male, gunshot wound to the chest and back, pronounced dead on arrival.”

“28-year-old female, front seat restrained passenger in motor vehicle accident, distal upper extremity fracture. The driver pronounced dead at the scene.”

I’m sitting in morning report listening to the barrage of death and tragedy again. Just 5 minutes ago, I overheard a colleague tell a patient their partner had died. I listened to the patient’s sobs through the thin curtain, her devastation without privacy. Then watched as the same colleague pivoted from breaking her heart to presenting the overnight trauma patients minutes later.

I’m a second-year emergency medicine resident, and I am exhausted. Every day, I bear witness to tragedies. I watch as patients experience the worst days of their lives. Pronouncing patients dead and hearing the cries of their loved ones. And immediately after these events, often horrible tragedies, on top of worsening emotional fatigue—my colleagues and I are expected to just get on with it. We finish our notes, call consultants, check off our to-do boxes, and see the next patient. Sometimes this is easy. We’ve learned to suppress our emotions, compartmentalize, and deal with death and loss by not dealing with it. We become callous, jaded, cynical. I’ve seen this during codes—“No way we get them back.” “Drunk driving, probably.” “Maybe at least I’ll get a chest tube out of this.” Flippant comments, just another code, just another death. We have done this before. This won’t be a problem. And maybe it won’t be, until it is. Until this not dealing with the emotional turmoil surfaces in other ways.

I feel this internal disquiet, unease, even after just a few years. I’m angry—angry at patients. Why did this patient come in during my night shift for earwax impaction? Do they really have nowhere else to go, no urgent care to call? Oh, and the next patient isn’t vaccinated against COVID-19, even after all of this time. Don’t they know about the dozens of deaths I’ve pronounced upstairs in the intensive care unit? Selfish. Inexcusable. In the next room, my patient wants to leave against medical advice. I can’t help but think, “One less hand-off to give, one less hospitalist to give report to.” I feel numb.

But really, I’m angry at myself. How can I feel this way? How can I be thinking these things? I hold empathy for patients and human connection in the highest regard. I want to understand people, to reach them where they are. So how did this happen? I feel disgusted with myself. I feel empty. I tell my parents about the patient I saw die in front of me in the emergency department. I remember the patient’s eyes—afraid. A massive gastrointestinal bleed, we did everything we could, but the patient didn’t survive. The patient’s family stood nearby watching as I inserted the endotracheal tube. I remember the patient’s glasses; I took them off and tossed them aside in the fray as I prepared to intubate; tiny drops of blood covered the lenses. Where did I put them? Did the family get the glasses back?

I feel disconnected from my nonmedical friends and family. It’s difficult to relate to them and difficult to care about other issues like world events and politics. My friends in business school joke about their bad days at work, their colleagues, their emails. Meanwhile, my bad day at work is a child dying in front of me. Hearing his mother’s screams as she falls to the ground, hands clutching the hospital bed as we declare time of death. Blood on the sheets. The alarming of the ventilator.

I am constantly on high alert. I jump at noises—the sounds of people running, raised voices. The noise of a wheelchair being pushed past me into the trauma bay, the patient slumped and unresponsive. My pager going off and saying, “CARDIAC ARREST.” These signs always accompany tragedy. They always indicate a critically ill patient, an unexpected code, intubation, death.

My colleagues and I witness so much tragedy. I tried to protect myself by not feeling but that has made me hardened and angry. I didn’t know how else to protect myself because feeling the pain all of the time was too much. But I don’t want to feel angry, dismissive, and patronizing. I see others doing the same, and I see myself in them. “Another COVID-positive patient who’s not vaccinated. I can’t even care at this point,” or “The patient just needs to toughen up.”

As health care workers, we are overworked, exhausted, suffering, and emotionally drained—and the system simply does not provide time to cope. I stand in the doorway of that child’s room, the mother still laying across the bed. I am frozen. I can’t think except to wonder where the nearest bathroom is as my eyes start to water. My phone rings. There’s another patient. I have to go. I tear myself away from the tragedy in front of me.

For many physicians, therapy is still largely seen as a weakness and psychiatric medications are still talked about in whispers. Sure, it’s true we have come a long way as a profession. Sure, we have group debriefs. Sure, we talk about difficult cases more than before. But we have so far to go. I have colleagues who budget for and pay out of pocket for therapy and antidepressants, afraid that their vulnerability will be detrimental to their future careers. Others don’t seek help at all. In reality, they are right to be skeptical. Change is needed. We need less stigma around mental health and more access to no-cost therapy through residency and beyond. We need the ability to take a few hours, maybe even a day, after a traumatic case as opposed to feeling guilty about calling in sick while a another resident has to cover. We deserve more time and space to process and heal. We can’t help our patients heal if we are breaking inside too.

I’m trying to be more present in my sadness. After a code ends and time of death is called, I stay for a bit and observe a moment of silence. I take this time to feel the pain before getting back to work as usual—honoring the patient, mourning them. On my drive home, I can still hear the heartbreaking screams of that mother echoing in my ears. I still remember the way my patient with the gastrointestinal bleeding looked at me, face pale and afraid. I see these patients over and over again and feel flashes of heartbreak. I won’t forget them. I can’t.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Diana Halloran, MD, Department of Emergency Medicine, Northwestern Memorial Hospital, 211 E Ontario St, Ste 200, Chicago, IL 60611 (diana.halloran@northwestern.edu).

Conflict of Interest Disclosures: None reported.

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    16 Comments for this article
    EXPAND ALL
    Thank you...
    Susan Boyko, MEd, PhD | Northern Ontario School of Medicine University
    Powerful. Thank you for saying what needs to be said.
    CONFLICT OF INTEREST: None Reported
    The Canary is Drowning
    Justin Starren, MD, PhD | Northwestern University
    Powerful and well written piece. Thank you.

    You are not alone. Healthcare and education in the US are both broken systems, built on assumptions that have not been true for decades (if ever). The stresses of Covid have pushed those broken systems to near collapse. Residents, nurses, and teachers are all caught between what Americans expect the system to be and what it actually is. Physicians are expected to be empathetic and emotionally connected to patients, while the insurance companies that determine care make cold profit calculations. They are expected to "just work harder"
    when the number of residency slots has not kept up with either the population growth, or the medical school enrollment growth. The humanity in the nursing profession has been permanently damaged by endless cycles of optimization and profit maximization. Teachers have been losing ground against inflation for decades, and are now being physically and psychologically attacked for trying to do their jobs.

    These suffering individuals are the canaries in the proverbial coal mine. Unfortunately, the canaries need to ask themselves whether they have the emotional reserves to keep doing the "right thing" when the systems that employ them no longer cares.

    Many of us have decided that we could no longer tolerate the cognitive dissonance and moral injury. We have chosen to leave professions that we once idolized in order to save our mental health.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    The Life we Chose
    Richard Shara, MD | Retired
    I read Dr. Halloran's article with a great deal of compassion and some tears since I lived that life for 37 years. I wish I could say it gets better but alas it mostly gets worse. It got worse during my years in the ED and I know it's continued to worsen in many ways. As physicians we want to help people but as emergency physicians we want to save lives. However, almost every day we are confronted with death and sometimes the truly awful. Things no one should see and no one outside our field can really comprehend. I frequently have lunch with 2 of my former partners. We talk about what was good and bad in our past, mostly the bad because we were there and our wives and families cannot share what they never experienced. Still we agree that it was the right career and we chose it knowingly.

    I wish you the best and thank you for your sharing this piece of your mind.
    CONFLICT OF INTEREST: None Reported
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    PTSD
    Charles Ralph Smallhorn | General Practitioner, Queensland Australia
    Interesting emotive article. After fifty years when talking with colleagues I am amazed at how many have PTSD and all from different specialties. Perhaps MRI or some other screen before starting medical courses will predict who will get PTSD as is being done in military special forces before deployment. My training bosses who were WW2 vets would say toughen up. We have moved on.
    CONFLICT OF INTEREST: None Reported
    Finding a Lifebuoy
    Amy Getter, MS, RN | Palliative Care Solutions
    Thank you for sharing so honestly what happens when too much is demanded of a person. I am very sorry that you often feel your work does not live up to your expectations for yourself, and recognize this feeling which destroys a sense of meaningfulness in the work you do. The well of empathy can run dry even when you know that being present can make all the difference for a family in crisis.

    Like many of us who chose a profession that demands expertise and compassion in the midst of acute human suffering, exhaustion and
    burnout are a real risk that must be identified and taken care of. Our profit-oriented medical system expects "Physician heal thyself" without providing the how and where, and penalizes those who do seek professional help. This has to change.

    Thankfully you know to give yourself moments to find peace in the midst of sadness, and seek out others to share this with.

    CONFLICT OF INTEREST: None Reported
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    Thank You, and Forgive Yourself for Being Human
    Lisa Harmer, MD, MBA | Retired
    Thank you for such a powerful and important piece. I attended medical school 30+ years ago. I’m a medical zebra, and am now the oldest living woman in the English literature with the variant of my syndrome. My parents were told — when I was an infant — that I was deaf, blind, cerebral palsied, autistic, and retarded, by an internationally renowned children’s hospital. They were also told I’d be dead before I reached my first bday, and the “best” option was to institutionalize me and have a “replacement” baby ASAP.

    My mom didn’t follow that advice.
    I taught myself to read when I was 3, skipped grades through school & graduated from HS at 16. By the time I was 5 I knew I wanted to be a pediatrician, because I thought I could do a better job at it than my stable of surgeons.

    During my 2nd year of med school I was diagnosed with ovarian cancer. The dean asked me to submit my letter of resignation that same day. I demurred, instead asking that I be allowed to complete my 2nd year half time. The dean told me no one went to med school part time. Fortunately, the ADA was passed a couple of years earlier, and I said I expected my civil rights to be upheld by my medical school.

    The man was not pleased. He asked me to wait outside while he first contacted the medical center legal team, then the university legal team. Both agreed if I could prove I was physically disabled (no problem!) and was denied this reasonable accommodation, I could sue, and the medical center/ university would lose.

    So I persevered. However, having ovarian cancer in your 20s is rough. I was already seen as defective by the medical school, so paid for mental health services and antidepressants out of pocket.

    Things are improving in this area, but not fast enough. Don’t be angry or disgusted or disappointed in yourself because your job can be overwhelming at times. Treat yourself as gently as you’d treat one of your patients, access whatever support you need, and do the best you can each hour, each shift.

    No one can — nor should — expect more from you than that. We practice medicine. Meaning we sometimes make mistakes, small and large. But every mistake is also an opportunity to learn.

    Keep learning, and keep taking care of you. Our healthcare system won’t, so you need to set your own limits. And if that means taking a day off, do it. You’re worth it.

    Thank you again for writing this piece. I hope it might expedite change in our field.

    Lisa
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Serenity Prayer
    Robert Mc Namara, MD | Temple University Hospital
    You are heard. I am in my 40th year of EM in level 1 trauma centers in Philly. The “Serenity Prayer” has been my touchstone. It is on my office wall. I try to divert the cynicism by telling myself it could have been me or one of my children on that stretcher if not for good fortune. Of course it doesn’t always work but I forgive myself these imperfections. I have found meaning beyond the bedside trying to keep Private Equity and corporations from exploiting my colleagues and by coaching sports. I hope you find equipoise.
    CONFLICT OF INTEREST: None Reported
    The Tail that Wags the Dog
    Beth Boynton, RN, MS, CP | Boynton Improv Education
    Your story is so powerful and sad and compelling. As a nurse for over 30 years, over half of which is devoted to improving communication, collaboration, and culture, I want to focus on this excerpt: "We need the ability to take a few hours, maybe even a day, after a traumatic case as opposed to feeling guilty about calling in sick while a another resident has to cover. We deserve more time and space to process and heal. We can’t help our patients heal if we are breaking inside too."

    We, and I include all members of the healthcare
    workforce, need to have a stronger, more collective voice about needing more time. More time for a lot of things including your point of coping with trauma. We need more time to do things safely, to manage conflict productively, to give and receive constructive feedback, to care for ourselves and each other. And we need to have the skills to say "no" and to respect each other when we do.

    Dr. Danielle Ofri, captures this well in her June 2019 NYT’s Op-Ed, The Business of Healthcare Depends on Exploiting Doctors and Nurses, the subtitle of which says "one resource seems infinite and free – the professionalism of caregivers."
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Fantastic
    Aurelia Faria, MD, Occupational medecine | AIST89 / G France
    You put the words over my feelings. Caring for people for 33 years, now exclusively doing prevention because I couldn't bear the weight of all that suffering and the pressure of this profit-oriented system. Bravo!!
    CONFLICT OF INTEREST: None Reported
    Time to Demand
    Suneel Mahajan, MD | Private Practice

    Very powerful and unsettling depiction, Dr. Halloran.

    It looks like physicians are fighting these waves of trauma understaffed and underfunded. The training programs should provide more support, with more time away from the carnage, and more mental health support. They need to refocus attention on the staff rather than building ever more grandiose buildings and funding a few dozen VPs.

    CONFLICT OF INTEREST: None Reported
    If
    John Carey, MBBChBAO (MD) | Galway University Hospital, Ireland
    An excellent article, and a brave one. Huge kudos for trying to wake up the profession and providers of the services, staff and education. You are not alone; there are thousands/millions the world over. You are there because you do care. But you are exceptional, because you chose to speak out so eloquently. Please never stop believing or caring. Sometimes we need to remember those we saved, and how good that feels. If we remember we can save many more, if we always help those who need it, if we make their passing just a little easier, if we change the attitude and education in medical school and PGT programmes on death and coping, we can improve the lives of our patients, healthcare staff, and the imperfect world we live in. Don't stop caring, don't stop writing, but do take a little break sometimes to remember all the good you do. If I ended up in your emergency room as a patient it would be a huge relief to know you are my doctor, because you care.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Here is a Lifesaver
    Josh Torgovnick, M.D. | Mt Sinai Hospital NYC
    I read the article several times and am disturbed that Dr Halloran is only in her second year of training and feels this way. I trained in Internal Medicine and then Neurology, which was my career. For nearly twenty years my practice was AIDS and death was the rule until 1995 and beyond. Parents buried their children, a complete reversal of the usual life course, but we got to know our patients and the families. Tears were a rule and my colleagues and I shared the misery with the patients and families. My friends and I also bonded in a battlefield kind of unity, helping each other along the way.The ER is a different place and the bonds will have to be different. The Electronic Health Record takes some of the soul out of a doctor. I can't explain this better, but I used to sit around and discuss patients with colleagues and most importantly nurses as we hand wrote our notes. Dr Halloran will forget these patients. That luckily is just what the brain does. I hold onto my lists of autopsies and look at it periodically.

    How to help yourself and heal will be a project. I recommend the book The Body Keeps The Score by psychiatrist Bessel van der Kolk as a look at what the brain can do with a little help. Finally, Mark Twain said "Dance like nobody's looking, love like you've never been hurt. Sing like nobody's listening." Van Der Kolk in the book suggested yoga; it is to a large extent in the breathing as you pause after the code.

    CONFLICT OF INTEREST: None Reported
    READ MORE
    The Times They Are a-Changin'
    Victor Ettinger, MD, MBA, FACE, FACP | Retired
    It is many years since I trained in the 1970s, but so much has changed in healthcare during that time. We as physicians have relinquished our agency to health plans, PBMs, governments, and more. In addition, there is so much more we can potentially do to help patients and so much less we can do to help ourselves because we have given control away to the system.

    The result is that we are burned out, retiring earlier than ever and in greater numbers.

    The upcoming graduates of medical training must do what we older physicians did not.
    They must stand up to the system and loudly and clearly say 'Enough is enough and we will not take it anymore.' They must retake control of medicine and once again, if ever it was, make it 'Of the people, for the people, and by the people'.

    This was beautifully and thoughtfully written and so obviously true!

    CONFLICT OF INTEREST: None Reported
    READ MORE
    Unionize
    John White, MD | University Hospital Emergency Medicine
    Unfortunately we are pawns in this brave new world. Once one grasps that we have been converted to employees (a fancy name for workers) it starts to make sense. The growing lack of respect, the patronization, the stagnant wages (and yes we are technically wage earners - no passive income or residual in EM-the only thing that ‘scales up’ in EM is the number of patients seen per hour and the number of boxes to check), and one of the few forms of employment where technology creates more work rather than improves productivity . Once one makes this paradigm shift, the answer is simple and inevitable. We must unionize, as all employees have had to do over the years, instead of tilting at windmills, handwringing, and yes, depression. Of course none of this is unique to our specialty, what is unique is our inability to push back because of our selflessness and denial and structure of our practice.

    The problem is not in the stars and is beyond remonstration - it is structural and corrupting on all levels. We are employees, sometimes abused, and we must push back with the time-honored and only means any worker has in America: unionize. Unless we do, we are part of the problem. I doubt any of us went to medical school to be victims or spend time at age thirty identifying ‘side gigs.' Past generations of physicians did not need to engage in daily meditation, or develop wellness programs to’ get through the day. Start thinking about yourselves and your investment in your career and calling (financial, physical, emotional, chronological), and unionize.

    CONFLICT OF INTEREST: None Reported
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    Dr. Lorna Breen Act
    Samuel Benson, BA, EMT-P | EMS
    On March 18, President Biden signed the Dr. Lorna Breen Health Care Provider Protection Act, named for a Columbia emergency medicine physician, into law. The act will provide federal funding for mental health education and awareness campaigns aimed at protecting the well-being of health care workers.

    Please, everyone, take care of yourselves.
    CONFLICT OF INTEREST: None Reported
    Being Present
    William Foreman, Ph.D. | California Department of Corrections & Rehabilitation
    Thank you for being present with them in their suffering.

    You remind me of my ever-present memories. I was a Navy Corpsman (think medic) during the war in Vietnam. I didn't go to war, but worked directly in treating young Marine and Navy boots with N. meningococcus infections. After discharge I worked the first two years of University, first on ambulances then in a county ED. I learned to not tell others of the horrors, but of the funny or remarkable events. Memories fade until they reemerge. I allowed myself to be present with them in their final moments
    or in their misery.

    Since 1985 I have responded to numerous and varied traumatic incidents and provided psychological care to patients suffering aftereffects of exposure to trauma. It's not all PTSD. I learned to say to myself, "It's their trauma not mine." Also to process my experiences, I write a lot of my thoughts as you did and I have colleagues that do the same work. Currently, I successfully treat inmates who went through unimaginable childhood trauma in their homes compounded by trauma in the streets and in prison. The effects of their psychological trauma clearly contributed to their bad behavior. "It's their trauma not mine," but I can be there with them as they heal and become better.

    Think of seeing a trauma psychologist much like seeing a personal trainer when you want to strengthen a certain muscle group and need expert guidance.

    Take care. Thank you for your heartfelt narrative and thank you for your work.



    CONFLICT OF INTEREST: None Reported
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