Crozet Annals of Medicine: The Cost of Caring

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Like most people I sleepwalk through parts of my waking life, not consciously noticing much of the world around me. Driving in to work is a perfect example. I do it automatically, my car seems to know the way itself, meanwhile I am lost in my inner thoughts and only upon arriving do I realize I have made the journey without really seeing much of it.

All of this changes however as soon as I approach the ER to start my shift. All of my senses engage.  Thousands of data points begin to register and coalesce into impressions, diagnoses, plans and decisions. I am in the zone. In a previous column I described this as gestalt, the ability to absorb many disparate inputs to form a clinical impression. This is very helpful toward effectively doing my job, but the associated hypervigilance has a cost.   

Today there are six police cars in front of the ER and three ambulances in the bay. Small knots of people are huddled together outside, smoking. I recognize the anxious energy in the body language, the hunched shoulders and the sharp glances. Gestalt—something has happened. 

As I enter I pass the pediatric waiting room. A woman is seated in a child-sized chair. Her head is bowed and she is weeping. Two women kneel in front of her, touching her shoulders, comforting her. Gestalt—something has happened to a child. 

I walk through the double doors and into the ER. Dozens of staff are milling about aimlessly. I catch the eye of a senior resident, but he doesn’t acknowledge me. He looks bewildered, unable to think of what to do next. This is very unusual for him. Most of the staff appear lost in the same fog.  Gestalt—something terrible and irreversible has happened to a child. 

I find the attending physician I am relieving. Her face is crestfallen and her eyes are moist. I have known her for years and I have never seen her like this before. She shakes her head when I ask her what is going on. But I know what has happened. A child has died in the ER. Not a chronically ill child; that carries its own sadness but doesn’t strike down the entire staff. A healthy child who had been playing happily earlier that morning has died. 

I take over a dismal and dysfunctional ER. The necessary work is getting done but there is no joy in it. People are going through the motions, muscle memory overcoming inertia to allow us to continue moving forward. 

I sit and chat for a while with my colleague who cared for this child. I counsel her to take time to process this grief and anger. Her reply to me is typical. She plans to compartmentalize this event and move on. It is what we all do. But it has a cost.

I am twenty years further into this work than my colleague and I try to warn her that these tragedies are cumulative, they don’t go away and they add up. We used to say that every physician has a graveyard in their head. In that graveyard are the names and faces of every one of the fatal mistakes that physician has made. In that graveyard are also all of the tragedies that physician has borne witness to. 

I don’t know what the limit to my own graveyard is, how many more tragedies I can witness but I know some of my colleagues have reached their limit and have developed Post Traumatic Stress Disorder (PTSD) as a result. This is the cost of that hypervigilance that is required to function well in the ER. 

PTSD symptoms include sleep disturbance, nightmares, depression, hyper-alertness, withdrawal, generalized irritability, frequent changes in mood, guilt, avoidance of activities promoting recall of the traumatizing event, and increased muscle tension. In fact as my colleague got up to go home she winced in pain. 

“My back has spasmed,” she told me. I gave her a knowing look.

“It was hurting before this case,” she countered.

Studies of emergency physicians have clearly shown that the more a population is exposed to traumatic experiences at work, the more prevalent the symptoms of PTSD become. Symptoms increase with the total number of ‘fatal incidents’ witnessed, total number and severity of exposure to traumatic events, and years of on-the-job experience. Overall the incidence of PTSD is 15-17 percent in Emergency physicians as opposed to about 6 percent in the general population. This is the cost of the work we do. 

There are a few protective factors to decrease the rate of PTSD. Strong support networks at home and at work are the strongest predictors of resilience in the face of potential or eventual PTSD. Reflective writing (like this column) has been shown to help. And increasingly psychologists are studying the flip side of PTSD, post-traumatic growth. Some resilient individuals find life-affirming wisdom after surviving horrific traumas. 

So I will give you some life affirming wisdom gleaned from watching what most ER docs reflexively do after these kinds of days at work. Go home and hug your kids. Every day.  

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