On January 2, 2023, Buffalo Bills Safety Damar Hamlin collapsed secondary to cardiac arrest on live television, horrifying millions of Americans. We saw broadcasters, fans, players, and reporters crying on live TV as they watched the psychological trauma of a resuscitation. “No one should ever have to witness this” was a common refrain during the broadcast. For that one night, America was privy to what thousands of health care workers witness daily.
Fortunately, an elite team of highly trained medical professionals successfully resuscitated Damar Hamlin. But while Mr. Hamlin will have a fruitful recovery, thousands of health care workers will go as usual without mention of the 321,000 unsuccessful cardiac arrests, which end without a happy ending. The U.S., traumatized by a successful resuscitation, won’t hear about CPR’s 90% failure rate. They’ll never feel the cracking of ribs during compressions or experience the screams of family members when they are told their loved ones are dead. They also won’t see the stoicism of the medical staff post-code, who carry on with their shift after someone is declared “expired.” We are on the heels of a pandemic with excess mortality of 500,000 to 2 million people. It’s no wonder health care faces the largest staffing crisis this century: U.S. legislators, hospitals, and medical employer groups remain incapable of properly addressing burnout, moral injury, and mental health in U.S. health care workers.
In the U.S., medical doctors have the highest rate of suicide in any career field. U.S. female physician suicide deaths are 250 to 400% higher than in other fields. Medical students have 15 to 30% higher rates of depression than the general public; 75% of residents have signs of depression. 44% of nurses have been subject to physical violence, while 68% have endured verbal abuse. 5.5% of Nurses have suicidal thoughts. Over 75% of health care workers in a 2020 survey endorsed feeling exhausted and burned out; 9 out of 10 endorsed feeling stressed.
Once in my career, I had two back-to-back shifts where I unsuccessfully attempted to resuscitate one-month-old infants. This would be uncommon for all but the busiest pediatric EDs in the country, let alone a small, suburban community hospital. I wonder how many hospital administrators, private equity partners, health insurance VPs, tech “disruptors,” or congressmen — all of whom love to give lip service on how to “fix” U.S. health care — can contemplate the dread of a mother shrieking after you tell them their child has died. Then repeat that one day later. Do they contemplate the high stakes of medicine in between their metrics, P&L statements, endless meetings, tweets, or 15-minute meet and greets with constituents/lobbyists?
There was no debrief, no calls, no emails to discuss “what no one should ever have to witness.” No one came by and asked the staff or me how we felt after watching two newborn infants die on consecutive days. Life continued as usual: Keep your head down, don’t think about it, keep pushing, detach/compartmentalize/move forward. Medical consultants now talk about building resilience in health care workers. Yet despite having some of the highest resiliency scores, health care workers still burn out at higher levels than the general population. I wonder if any resiliency consultants have advice on how to best continue your day after putting a baby in a tiny body bag.
Outside of my residency and a few self-selected lectures on burnout at medical conferences, I’ve never been to a training seminar on properly dealing with the horrific traumatic events we see daily in the emergency department. I have, however, spent at least 40 hours of continuing medical education on mandatory patient satisfaction lectures. I had one lecture by a former executive who lectured us on making ERs more like Disney World. I laughed at myself while he talked about customer service, recovery, and other steps Disney takes to ensure the highest customer service and experience. I wondered if the workers at Disney were ever asked to code a baby, then tell the mother the baby was dead, then expected to deal with a “guest” 10 minutes later to meet throughput goals. And with a smile, no matter how trivial the “emergency” complaint. Then repeat the same exact thing a day later. Or how many Disney employees were forced to treat a “guest” who threatened physical violence, attacked them, and was belligerent to the point of requiring police restraint but yet necessitated a full examination and treatment?
At another point in my career, I had to code a police officer. The officer died, and I had to tell their teenager they had passed. After discussing it with the family, I went back to work. My next patient, who was there for a sprained foot, complained about the wait and the noise (screams?) coming from down the hall. Based on the incentive system of our U.S. health care system, we got “dinged” for mortality of an unsurvivable injury at a non-trauma center, would get dinged again if I didn’t see the sprained foot patient within a certain amount of time, and would be reprimanded one final, insulting time with a patient satisfaction survey weeks later if the patient complained about his/her wait time for a sprained foot in the middle of the night after the entire department had just spent an hour in a code. And we wonder about burnout.
Perhaps instead of pizza, mandatory resiliency modules, or yoga lessons, the U.S. health care system should prioritize evidence-based treatment, proper staffing, health care access, and mental health resources for health care workers on the tail end of a pandemic. Instead, Congress gave physicians reimbursement cuts (while insurers received an 8% raise). Half of the state medical boards require disclosure if you have had treatment for mental illness, and some even require entering medical board-sponsored programs, which cost more than tens of thousands of dollars. Meanwhile, Hospitals continue to prioritize patient satisfaction, which is actively encouraged by CMS through bonus incentives tied to scores, unfairly punishing critical access hospitals with the sickest patients and longest waits. So, the rich, superfluous suburban hospitals get nicer fountains, while the critical access hospitals live month to month or shut down completely. This is despite the evidence showing higher patient satisfaction scores being associated with higher medical utilization, higher health care and prescription drug costs, and increased mortality.
During the pandemic’s beginning, one of my colleagues sent me a patch that read, “no one is coming — it’s up to us.” It was rather prescient — no one ever really came to help with the pandemic. We had politicians squabbling over public health measures, non-scientific talking heads questioning whether vaccines actually worked, hospitals asking for government handouts to pay for staffing which they used to exacerbate staffing issues by paying more for mercenary travelers, and U.S. insurers making record profits. Health care workers had to band together to get through the pressures and terrors of the pandemic. The American public, media, hospitals, health care businesses, and Congress are wondering how they can fix “burnout” and solve a staffing crisis in American hospitals. The answer is you won’t. We’ll have to figure it out ourselves.
Damian E. Caraballo is an emergency physician.