A strategy for working in the ER: Serenity now, insanity later

When I meet a new person, and they find out I am a pediatric ER doctor, the most common response is a variation of: “Oh, that must be hard,” accompanied by a sympathetic frown.

The statement is well-intentioned, but I wonder — is their view of medicine closer to “Grey’s Anatomy” or “Scrubs?” (Hint: “Scrubs” is a better show and a more accurately reflects life in medicine.)

I imagine they think my days/nights are filled with miserable, screaming children trying to get away from me. Sure, that’s my home life in a nutshell, but in the ER I can give the kids a sedative and walk away. Everyone’s happy.

While we do see some very ill and injured children, I’m fortunate that most of our patients eventually get better and go home. For my colleagues in the ICU, critically ill or dying patients comprise a greater part of their day-to-day lives. It’s never welcomed, but for them, it is certainly more of an expectation.

While the ER may appear chaotic to a patient, for those of us working, there is an ebb and flow and organization that is not apparent. Managing the flow of a busy ER is a combination of chess, checkers, and Tetris.

When we take care of a critically ill child, most (not all) of the time it’s with little warning. You can spend an entire shift treating kids who are “fine,” but you never know when you will be called to the trauma bay because EMS is three-minutes away with a child who sustained a gunshot wound (an all too common occurrence in my city).

Anticipating what’s coming in the door and allocating resources accordingly, frequently shifting to make pieces fit, requires training and experience. The arrival of a critically ill child doesn’t necessarily disrupt the flow, but it requires a bigger adjustment. Other times, it’s akin to dropping a bowling ball onto the game board. When you’ve finished dealing with that child, the biggest challenge isn’t getting the pieces back on the board; it’s putting the board back together.

If you don’t have a strategy to prevent your internal board from breaking, you can’t pick up the pieces. Everyone eventually develops a strategy — if you don’t, you can’t do the work.

A few months ago, I had consecutive, busy, overnight shifts with potential for my internal board to be broken.

The first night, around 2 a.m., parents brought in their infant with a complaint of difficulty breathing. It was obvious when entering the room the child was critically ill, and it quickly became apparent that his illness was a result of being a victim of physical abuse. A severe head injury was causing most of the symptoms.

While no one was confessing to injuring the child, it wasn’t a difficult diagnosis to make. Based on what we did know from the parents, it seemed highly likely that one of the caregivers in the room with us was the person responsible for injuring the child.

So what do we do? Not to be cliche, but we did our job. We took care of the child and put aside any emotion or outrage. We stabilized him, called the specialists whose assistance we would need, and ultimately were able to transfer him to our colleagues in the pediatric ICU. We certainly didn’t make any accusations.

I don’t know how long I spent in that room — maybe 60 minutes total. It was spread out, however, as while this patient was critically ill, the rest of the ER kept going. During the overnight shift, we have only one attending (supervising) doctor, so I am responsible for seeing every patient that walks in the door.

We don’t tell the rest of the ER that there is a child who may be near death — the nurses and residents who are free keep going, and they all ultimately have to wait for me to rejoin them to help direct the care. EMS doesn’t divert their ambulances, and we don’t put a sign on the door directing parents elsewhere.

The next night near the end of a shift, we received a call from EMS that they were bringing in a patient in cardiac arrest — the child was not breathing and had no heartbeat. The only details we had were that he had a recent outpatient surgery.

This child was more critical than the one from the prior night, and, unfortunately, we could not save him. As the senior physician, I kept mom updated on what we were doing, while also supervising the resuscitation. The responsibility for telling her we had to stop CPR and that her child was gone was also my responsibility.

Unlike some ERs, we let parents stay in the room during situations such as this, so they can better understand what is happening to their child. We have a social worker or resident physician (or both) by their side updating them when doing CPR. Even when we’re providing chest compressions, however, I make a point to personally give them updates. If or when it’s time to stop — because we can’t save the child — I want to make sure they know we did everything possible.

This particular child had a rare but life-threatening complication of an extremely common surgery — a surgery that one of my children had a couple years ago. This case was not only more challenging to be involved with in terms of providing medical care, but it was also more emotional. Both because the child did not survive and because of family circumstances we later learned.

Again, the rest of the ER keeps on going. Patients were waiting, some of them also very ill (though not critical), and none of them had any way of knowing what we had just been doing.

So what strategy do I use to keep going through moments such as those?

This is a funny clip from “Seinfeld,” but it isn’t intended to make light of these situations. As a teenager, the “Serenity now, insanity later” concept had taken root in my head. I thought it meant I should never compartmentalize emotions or delay dealing with them. Because eventually, it would drive me insane. As an adult, I’ve realized that being able to temporarily compartmentalize emotions is a necessity, not just for work, but for life.

When working in the ER, going room to room sometimes means leaving behind a tragic situation, sometimes entering into conversation with a combative parent and sometimes trying to calm or diagnose a sick or upset child. When providing care for anywhere from two to 20 children at a time, a strategy is needed to focus separately on each individual patient.

I use physical cues to help me do this. My co-workers likely have never noticed (but maybe some will now), but I make it a point to close the door and curtain whenever I am in a room. It sounds obvious (and simple), but it’s astounding how often I see one or both open when I am not in a room. At times, I close the door behind others when they go into a room and don’t do it themselves.

Closing the curtain and the door not only provides the patient the physical privacy they deserve, I use it as a mental and physical cue to separate myself from the rest of the ER. Entering a room and closing the curtain and door lets me enter a new world — I go from room to room and world to world, and each time I enter a new world, I can temporarily leave the previous world behind. I may only have a couple minutes to make a personal connection with a family and gain their trust — if I drag in a big bag of negative emotion behind me, I’ll end up drawing from that instead of the positives.

Even when I do shut the door, the rest of the universe always tries to intercede — pages, phone calls, people entering/leaving the room — but that door provides separation.

Only later, after my shift, usually when I’m alone, do I open up the mental doors. Sometimes on the drive home, sometimes on the couch in our living room in the middle of the night. Only later do I talk about it — with my wife or co-workers or colleagues who were involved in their care.

Everyone handles the stress differently. For some, an immediate discussion is necessary to be able to move on. Some may never talk about it and find other ways to process their emotion. We do have “de-briefings” immediately after or sometime later for certain cases — an open forum where those who were involved in the care of a patient can have a chance to share their emotions as well as discuss the case itself. It’s a way to help process whatever needs to be processed — grief, anger, sadness, etc.

My way isn’t right or wrong (well, I’m not a psychologist, so maybe it is wrong), but the key is to have a way. Without it, we can’t do our jobs, and we won’t be ready to help you or your child when you come through our door.

What do you think of my strategy, and what strategies do you use to get through difficult moments and keep up with your responsibilities?

“Rogue Dad, MD” is a physician who blogs at his self-titled site, Rogue Dad, M.D.

Image credit: Shutterstock.com

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