Emergency medicine is a supra
normal job where you are exposed to such
a volume
of stuff.
There's anger. There's misery. There's tragedy.
And even on a great day,
your cortisol and your adrenaline
are maxed.
Alright, ladies and gentlemen. Welcome back to the
podcast. We are here
graced by the presence of doctor Rob Orman
once again. Rob, thank you for being on
the show.
Thank you, my friend.
Always a treat chat with you. Always treat
me back on EBM. I love EBM.
You know what EBM reminds me of?
Tell me. A blue chip stock.
Oh. Yeah. We just got a bunch of
the monthly handouts.
They're basically the world's best review articles.
I mean, I know that's what you talk
about in this podcast. I had not seen
them for years.
They are amazing.
Blue chip stock.
Love it. They are pretty incredible. And thank
you to all of our authors who might
be listening today for continuing to write them.
They're amazing. Yeah. And They're great.
This voluminous
and all encompassing on a topic that's always
relevant to emergency medicine. It's pretty amazing. Both
the adult and the peds ones, honestly.
Yeah. We just we just got both of
them. Yeah. And there's some smart people that
write those things. I mean, I get the
pleasure of talking about it on the podcast.
And then occasionally, we get to have the
author on the show, and it just goes
to show you how smart they are because
I just sit there and You're the the
talking head.
I am. I'm basking in their intellectual
fortitude.
It's just it's amazing.
So I asked you on the podcast today
to talk about trauma,
And I didn't mean the type of trauma
that we're used to seeing in the emergency
department, or at least that we're aware of
seeing in the emergency department when we talk
about things like trauma alerts and
victims of trauma. We had a recent event
here in Tallahassee, Florida where I live, where
the Florida State University campus experienced an active
shooter incident.
And multiple people were shot, two people died,
and the shooter was also injured, all of
them taken to the hospital.
And there was a lot of discussion
around
what it would be like to work in
the emergency department
and
experience
an active shooter incident and be there
in order to accept these patients coming in.
And it got me thinking about
my couple of decades in practice and all
of the traumatic things that I saw.
You know, early on
in my career, I would go home and
share this stuff with my wife. It was
kind of a natural decompression and discussion.
But my wife is not a physician, doesn't
work in the emergency department. She has
experience in medicine and nursing, and so she
could lend that ear.
But after a while, she's like, I can't
really hear this anymore. This is kinda injurious
to my mind to hear what it is
that you're going through and what you see.
And so for the subsequent,
you know, fifteen, eighteen years, I just didn't
have a place to share it. It was
just this stuff that, you know, we get
expert at
compartmentalizing,
and it went from something I saw at
work to something I just stuck in a
compartment. And over
eighteen years, I think that compartment got gigantic,
you know, went from being the size of
a small bag to probably the size of
a giant house
of stuff I just kept stuffing in there
and putting away.
And it got me thinking
with this recent incident here that we had
in town
about
how much trauma
we experience
as
medical clinicians, especially in the emergency department, and
what the best manner is
to deal with that, or why should we
even deal with that, and what comes as
a consequence of not dealing with it. And
I couldn't think of anyone else better to
have that conversation with than you, doctor Orman.
Oh, thank you. I'm thinking about your wife
and Yeah. Hearing all this stuff that she
heard. And I just wanna tell you what's
popping up in my mind right now. I
mean, you and I have I don't even
know how many decades stacked on top of
each other in the ED and know what
this feel like and what this does to
our nervous system. And going back to the
days when you and I were retraining it,
emergency medicine was beyond a burgeoning field. It
was really establishing itself, and then it was
established. And now it's this leader. It's amazing.
And spent all of these years and decades
and, you know, people that were real trailblazers
creating this
specialty,
and how do we do this well?
And,
Sam, do you ever think about how amazing
it is?
Just the logistics and the tactics and the
strategies and how we operationalize
these different
aspects of medicine in the emergency department. It
really boggles the mind that that's where things
are right now. I mean, it is such
an amazing
field
medically,
and it's also
this
supernormal
experience
for a human being.
And I think about I was at the
ENT office the other day,
And, oh, then, you know, ENT is walking
in. We're gonna talk about surgery and all
this kinda that's not super normal. That's a
job. Or and I was hanging out with
a buddy, this man who's a radiologist.
And I sat with him for a couple
hours reading field. I don't know. It was
just fun. We're we're already that way. That's
not super normal. That's a job.
Emergency medicine is a super
normal job where you are exposed to such
a volume
of stuff.
And there's anger. There's misery. There's tragedy.
And even on a great day,
you're just your cortisol and your adrenaline
are maxed because the parallel processing that's involved
is
is past the horn of the bell curve.
And that's the normal aspect of it. And
you see these things, and and I'm going
back to think about your wife
that
you are taking this super normal experience which
has become normalized for you.
And now she is absorbing it with no
context.
And you are taking all of this stuff
that you see, and I I think of
it as stuffing it into the seemingly bottomless
stuff sack. You know, like, you put a
sleeping bag in that stuff sack. Like, oh,
wow. It's amazing how well this fits in
here. I got to put two sleeping bags
in here. Yeah. Your wife doesn't wanna hear
that. That is traumatic to even think about
and visualize that stuff.
You're talking about the shooting at it was
at FSU.
Yeah. And, I mean, these shootings have become
a regular occurrence.
And, yeah, these are big catastrophic events.
And, yes, those are traumatic, and those are
kind of big t trauma. And, you know,
some people are gonna do better with that
than others.
But let's just define
trauma
because we we know trauma. Trauma,
injury,
fix, better. Or injury, not fix, not better.
Mhmm.
But the kind of trauma we're talking about
today
is anything
that
overwhelms
our capacity
to cope,
and it leaves a lasting mark
on the nervous system.
We think that,
oh,
Rama's just in the mind.
It's just it's just how we think about
things, but
that's not the case.
That's have you ever heard of this book?
The body keeps a score. Mhmm.
So this is written by, I don't know
if I'm gonna say this right, Bessel van
der Kolk. This is kind of one of
the foundational books of trauma and trauma therapy.
And the trauma is not just something that
happens to you. It's something that gets stored
in you. You know? Like, what you're talking
about, your storage locker, that dark room in
your house. Right. It's it's in your mind.
Yes. It's in your nervous system. It's in
your physiology.
And
I think what you were getting at, Sam,
that over years and years and years,
that all of these events and all of
this stuff changes how you process
danger,
how you regulate
emotion, actually, even what you perceive as a
threat, and then how you sleep, how you
connect to other people. So how do we
adapt in emergency medicine? We push through. We
push through. And what you're talking about is
suppression,
and we suppress.
We know we're smart people. Listen to this
podcast.
When you suppress something,
it doesn't go away. It accumulates,
and it very subtly and silently or maybe
not so silently
rewires us.
Yeah.
Yeah. And that
experience or those experiences are not things that,
at least in my emergency department, that we
had any kind of tools to handle
protocol
for debriefing
or even
post shift
recommendations
for what to do with. It was just,
like, come to work, do your work, and
then go home. And, you know, I heard
stories about some emergency departments where they had
debriefing protocols after major incidents or major trauma.
Yeah. But honestly, I don't even know how
they do it. Because in our emergency department,
it was like, I literally would get through
a resuscitation
and then have to walk into
another room and deal with the now full
waiting room of patients who were waiting because
we were in a giant resuscitation. And, you
know, what am I gonna tell my next
patient who says my knee hurts? I'm gonna
say, well, that's great, sir. But
I just spent the last hour trying to
resuscitate a three year old child who was
with their parent and is now dead. And
I just finished my conversation with that parent,
so
you give me just a little bit of
a moment so that I can set my
brain around your knee pain and have that
discussion. It's like that. I could not say
that as a physician, but that's kinda what
I was being asked to do. They're like,
okay, great. You talk with the parent, now
go see the knee pain. And there were
no tools for, you know, how do you
handle that? What do you do next? It
was just cram it into that sack and
shut that compartment and and get to it.
You know what? I've gotta tell you what
I'm picturing in my mind to say that
is that I can picture the trauma bay,
room one, the big trauma bay
with all the stuff. I don't know. They're
like 17 exam lights in there and, you
know, a couple level one infusers, all all
this stuff.
And, yeah, you spend this time in there.
And what I'm picturing is I'm walking out
of that room, and I take a left
hand turn
nine times out of 10 after a long
resuscitation.
You'll have either the patient or their family
member standing outside of their room super pissed
off that they're waiting. And it's like, yeah.
Oh,
wait.
There's such a time compression
about that that, wow, I don't have room
to breathe.
I don't have room
to
even, you know, process us a little bit.
And I said, we think we don't because,
oh, I'm beholden to them and their impatience
and then, you know, their patient satisfaction, all
this stuff.
Almost everyone in the ED can wait for
you to do what you need to do.
The resus bay, critical patient,
adjusting event, that can't wait. That is immediate.
That is critical.
Everything else
can wait. It is hard for us to
wrap our heads around that because
you just think about opening up a tracking
board.
And he's like, oh my gosh, all these
patients need to be seen. I need to
do them all at once, and that kind
of this. But you know what? You don't
need to be everywhere at once. Those folks
can wait for what you need to do.
Now maybe that's finished a dictation. Maybe that
is to go outside
and just, you know, kinda down regulate for
a moment.
Maybe I don't know. But Yeah. That was
what popped up into my head is the
tapping of the foot. And I and I'll
tell you this. I was in New Orleans
One time. I was with my dad, and
we were at the Jazz Fest, and I
had a episode of biliary colic. I'd never
had that before. It was
so amazingly painful. I just
the more
painful than a broken bone.
And
the ED doc was busy. I was watching
him as a senior resident at the time,
and I was watching him running around the
ED. I was like, oh my gosh. This
guy is really, really just rocking it. And
we had about a four hour workup, and
he did all the things. It just takes
time in the ED. I can remember my
dad walking outside of the room I was
in. It was a curtain room and, you
know, just getting all huffy and puffy because
he was waiting. I was like, oh my
god. I am a part of this now?
I was so embarrassed. Like, dad, come on
in. And he he he couldn't resist.
Anyway, let's get back to trauma, shall we?
Well, the scenario is exactly that. So, you
know, you can imagine the trauma bay. The
patient maybe isn't in there anymore. Yeah. There's
8,000 pieces of used medical equipment strewn all
about the floor. There's maybe some blood on
the floor, and I'm finally getting a moment
to step out of the bay Yeah. After
having been in there for an hour and
may or may not have already spoken to
a family member. And now it's like, okay.
Just gotta move on. You know, go see
the kid with the fever. Go see the
knee pain. Go see the chest pain. Pain,
go see the belly pain. Yeah. Go see
whatever it is. And there were times when
I would be in there
resuscitating
with a roomful of nurses, and we end
it. And then we're all just standing there
staring at each other
going,
like, now what?
Now we just walk out of this door
and Yeah. Go back to doing what we
were doing before we got in here. It
doesn't feel right. It doesn't feel like the
next logical thing we're supposed to do. And
yet all of us just like, okay. And
out we
went. And that just it never set correctly.
It never felt like the right thing to
do in that scenario.
And it leaves an impact. The next day
for the rest of the week, every time
I walk by that room, I'm thinking about
that case. It takes a toll.
And what am I supposed to do with
that? I wanna pull back a little bit.
I do wanna talk about that. You know,
what am I supposed to do with this?
But I wanna put it in a certain
context
of
what can happen with
trauma. So now we're talking about the trauma
that gets stored in us.
And
so what you're talking about is
the habit
that we all get into or all well,
almost all of us get into. I certainly
would include myself in exactly what you're talking
about,
is thinking that we can power through
these experiences.
Mhmm. And that locked closet
or giant stuff sack
will have infinite capacity, and we don't process
these things. And that's what you're talking about.
We we don't process
it. And
this is
an important inflection point
in these events
because
what we do with this,
how we process this, our relationship
to these events
can
skew things. Now this is not definite,
but can skew things either towards
integration
or disintegration
of
the event
of the trauma.
So that may be a term that isn't
familiar to the audience. So integration.
Can we integrate these experience? And I say
that because you and I both know that
it can't unhappen. Once it happened, it happened,
and it can't
not affect us how it affects us. I
mean, this will be hard to say and
hard to hear, but I would imagine that
you and I remember, I can speak for
myself that you remember
every
child that you have cared for who has
had an untoward outcome. I mean, you probably
picture them in your head.
It's just there.
You remember you feel a certain way. You
feel grief. You feel sad. Or, you know,
you feel feel shame. You feel inadequate. Or
you you feel something. Or you feel triumphant.
I don't know. It's just you feel what
you feel. Maybe this is a great recess.
I did the best I could. Or I
just feel sad. You're just gonna feel that
way.
So
integrating these experiences,
you can think of that as that means
we can metabolize
them. It doesn't mean we're okay with what
happened, but we have found a way
to carry it because we're gonna carry it
one way or another
without letting it
fracture us. Because we cannot outrun the trauma,
but we can integrate these events or we
can
not integrate these events. So integration means
acknowledging
what we felt,
letting it become part of our story and
not something that owns us
because we have properly
or adequately or at least metabolized it. Disintegration,
that is when our thoughts,
emotions,
our sense of self starts to
kinda break instead of working together as a
whole. So this event that happens kinda gets
stuck like a bug in the system rather
than becoming part of the program.
Yeah. And it can be
because we've experienced a single event that is
too overwhelming to fully process. It's kind of
a, you know, like a protective mechanism.
So the brain kinda stores it in fragments,
and it shows up as
you feel like you're not yourself. You can
have emotional numbness or sudden outbursts. You can
even have flashbacks or memory gaps.
And
the difference between these two
is the difference between
carrying the weight, because it is a weight,
with awareness
versus dragging it unconsciously
until we break. Let me pause on all
that before we move on.
Yeah. So trying to digest
the event
and making it a part of
who you are in some kind of cohesive
way so that you can then continue to
move on. And, you know, maybe acknowledging that,
yeah, now I'm changed because of this,
but this is who I am now and
still functioning as opposed to just
suppressing, I think, is the word you were
using before. Yeah. Because when you think back
on events,
you're still gonna think back on the event.
It's not that it's not gonna totally disappear.
Mhmm. So let's talk about this emotional storage
locker
for remote with us. So
why don't we talk about it? I think
what you're getting at one is habit. It's
just, hey. We just go about our business.
Mhmm.
And there is kind of a culture of,
I guess, you should say, toughness or being
strong, quote, unquote strong,
where
you're supposed to bounce back fast, compartmentalize,
and
move on.
Yeah. You know, you deliver the news of
death to a family,
and then, like, hey, the patient with belly
pain is negative CT, and they wanna go
home, and they're really upset. Okay.
So we don't talk about it.
And
what you were trying to do was
process this
with your wife. You're trying to process by
talking about it. Yeah. And so going back
to the Resus Bay,
yeah, there's so many different ways to do
debriefs. And and there is one thing about
debriefs is that, you know, if you talk
about it too much, you know, it's like,
hey. Let's do this debrief and then have
a systemic debrief, and then this departmental debrief
is gonna okay. That can end up being
unhealthy.
But these debriefs in the moment of, let's
just take a pause and say, what
what's going on? How how did this go
for you? What are you feeling? What am
I feeling?
And that can be done as a group.
One way to process we'll talk about in
the moment stuff if you wanna get that.
But one way to process is to have
a
set way
that you do in fact process.
And
what happens is is we get to the
end of a shift,
and we think, alright. I'm just gonna go
home, and maybe I'll watch fifteen hours of
Netflix and,
you know, veg out on YouTube or have
a beer or numb myself this way. Yeah.
And that stuff in the brain is just
kinda ping pong and ping pong and around,
and you're just waiting for the noise to
quiet. There's just a lot of unprocessed stuff.
Just go away. Go away. Let me be.
Let me become a civilian again.
You know that it is hard to walk
in that house
and be a human being.
You know? It's like, hey. Give me some
time. I just I need to recalibrate
my brain and my physiology.
So
I don't know if we've talked about this
on your pod before. So I I made
this free resource called the driveway debrief for
this thing. It's on my website.
It says roborman.com,
r 0 b 0 r m a n
Com. This is a driveway debrief. And this
is not the only way to do it.
This is just how I did it. And
so I made a it's like a guided
exercise, seven minute guided exercise. And before you
go to the
house, in the driveway or a block away,
if there's people who are gonna be like,
what what are you doing?
Take some breaths.
Take some deep breaths, and you breathe out
for twice as long as you breathe in.
And what this does is it activates the
parasympathetic
nervous system
because you are sympathetically activated. You know, you're
just on. You're just redlined or just below
it.
So take some deep breaths
just to settle yourself,
and then
if you walk through
the day,
walk through the day,
what happened in that day that was great?
What were the great moments?
What could have gone better?
And you just
look at it and process and take note
of how do I feel?
How do I feel about this stuff? Name
the feeling. Name the emotion.
Oh, sad, angry.
What can I learn from this day?
Alright. Now that's kind of a of an
intellectual aspect of it, and a lot of
the processing is meant to be emotional just
to, you know, to pull apart the threads.
And then you release
the day at the end of the day.
There's a visualization to do that. And some
and I'm gonna tell you, if you listen
to driveway debrief, some people say, oh my
gosh. That visualization
has changed my life. And other people, that
visualization is the weirdest thing I've ever heard.
I don't get it. So I'm just gonna
leave it at that. And there is an
aspect of catharsis
to that. And there's other ways to have
catharsis such as through nature, just, you know,
a forest bath, go walk in the trees,
or debriefing,
or
journaling
or some way to get those thoughts out
of your mind and
maybe a little bit more structured. And debriefing
doesn't have to be formal. What you're talking
about is Yeah. You know, in the recess
bay. It can be talking to a colleague,
can even be just going outside looking at
this guy
and
settling. Now I will say that
when you debrief, you want to be careful
that you don't start co ruminating
and
amping yourself up again, but getting it out
there and processing it verbally or in some
way,
incredibly helpful. I don't even know where we
started with that, but
I'm gonna throw the law back to you.
I think
there were oftentimes I was jealous of our
nursing colleagues
because we would have
some kind of event, and then we would
all go back to our desks. And our
nurses worked in this little
pod section where there were, you know, five
or six of them together at the nurse
station. And they would stop and
talk with their colleagues and and go through
what they just felt and what they just
saw. And, you know, sometimes they would take
a moment and they'll be in there maybe
crying or comforting each other or talking about
what just occurred.
And in the physician pod, which was just,
you know, literally 15 feet away from where
the nurses are sitting, it is me
and maybe a PA. There's not another physician
in there. And
I come back and I sit down and
I'm just
exhausted after what I've just gone through. And
I'm looking at the PA who is now
looking at me like
ragged
deer in the headlights, you know, maybe sweaty
going,
okay. Are you ready? Because I've been supporting
this department for the last hour, and I
really need to talk to you about, like,
15 people. And I'm going,
okay. I just I just need thirty seconds
to just take a deep breath. And then
I'm all here. So, yeah, I'm all ears.
And I'd look over and I'd go, gosh,
you know, like, look at them. Like they're
sitting over there
debriefing
talking they're, you know, collegial covering for each
other, the nurses who have been covering for
this one nurse. Aren't like, oh, I'm so
glad you're here. You can take your patients
back now. They're listening and they're talking. And
for us on the PA and physician side,
there's no other physician to see patients during
this time because of our pod system. The
pod is mine.
And it was just, you know, okay. Are
you done? Are you done playing trauma doctor?
Because now it's time to play a medical
doctor.
It was just it was a terrible way,
and it made me so jealous of what
the nurses had just 15 feet away.
The system is not set up for support.
It's not. It is definitely not. So a
couple things came up in what you said
there, Sam. And
this isn't directly related to what you're talking
about with the nurses, but
very tangentially, it kinda gets back to the
processing.
Is there is
a difference
between
reflective solitude. You know, you think about, okay.
I'm just gonna go on a walk by
myself out in the woods for a couple
hours and think or sit down and journal
or even, you know, or whatever it is
that I do that
is
solitude is so nourishing. This reflective solitude
versus
another situation where you're by yourself, which is
isolation.
And solitude can be healing. Right? Time to
process and reset, but isolation,
that's different.
You know? It's just kinda
I am
alone.
And one of the things that
can happen in that isolation and that's not
exactly what you're talking about with the PA
and, you know, the sweating, and I've met
managing this apartment.
One of the things that happens in any
event, anything that happens in our lives is
we immediately
start creating a narrative,
creating a story that we tell ourself about
what just happened.
And that story can help us flourish.
That story can weigh us down. It can
lead to either integration or disintegration
of the trauma
or the event such as, oh my gosh,
this is horrible. I'm not up to the
task.
That is more likely to lead to disintegrated
trauma. Mhmm. Okay.
I feel stress.
I am up to this.
No one else
in this hospital could manage this like me.
This is the best chance this patient has.
Those are stories during the event. And then
afterwards,
the story you're telling yourself
can go unchecked
when you are isolated.
I mean, there's so many things about that,
you know, when when you're getting back and
the PA is just sweating and
none of the things
that you really want to be doing are
happening in that moment. And Mhmm. If it's
alright, I'd like to shift gears a little
bit,
talk about
some in the moment things
to do.
Yeah. And because when we're talking about this
trauma
and these major events,
there's this idea of trauma stewardship. Actually, a
book called trauma stewardship. And that is how
do I take care of myself when I'm
in a system where trauma is going to
happen?
And it's things like paying attention to the
stuff that nurtures you, like sleep, like food,
exercise,
relationships,
whatever it is you love to do. And
how do I frame this? How do I
create the narrative? How do I process all
of that stuff?
Stewardship
of the trauma that's going to occur. And
then sometimes the trauma gets so big
that at anything that you and I talk
about on the show or any of the
things that you kinda you you DIY,
the trauma can get stuck.
It gets stuck. It gets disintegrated.
And then
then you need
some deep work. Things like EMDR
or brain spotting or working with a therapist
or, you know, somatic work or things that
are specifically
targeted
to manage that disintegrated
trauma.
And because, you know, it gets wired into
your nervous system. All of that to say,
these tools
are not a one size fits all. They
are not 100%,
but they are,
how do I approach this
in a way
that is sensible and workable
in my environment
to increase the chance
of integration
versus disintegration
of that trauma? Or not even that trauma
of just that event. It doesn't even have
to register as trauma, but to make it
more likely that whatever happens
becomes a cohesive
part of your narrative rather than something that
is disruptive in your life. How does that
land before we get into some tactical
stuff? Yeah. No. I like it, and I'm
totally tracking with you. So, yes, we all
know it can go wrong. And I think
if you've been in the emergency department and,
you know, worked more than a day, you've
probably already felt when it has gone wrong.
But there is a better way. And you're
saying there are some things in the moment
you can do as opposed to waiting until
afterwards.
And so tell me about what kinds of
things might make it more likely to go
well in the moment.
Alright. Yes. There's so much processing that can
happen afterwards. Just processing that ought happened before
having said, okay. Here is how I'm going
to be
addressing
the overwhelming likelihood that these events will occur.
Let's talk about that in the moment. And
so we have an anti burnout course
called Unburnable.
It's Mhmm. Primarily for emergency docs, like emergency
critical care.
We work on tools
to deal with the reality
of
what is happening in your job as an
acute care clinician.
Because it's just, you know, the job is
what it is. You think, well,
shouldn't be that way. Quite.
It's that way. But it is. Yeah.
Yeah. And this is
one of the tools that we teach, and
we teach it for a couple of different
situations. And
this is evidence based,
and
it is useful in so many different situations.
Whenever
you're just kinda getting amped up and
you feel like maybe things are getting out
of control inside or your physiology is taking
over or your inner critic is taking over
or some kind of
deleterious
narrative is starting to push down the accelerator.
So this is
dropping anchor. Have we talked about dropping anchor
No. On the show? Alright.
And this is one of many techniques. And
I'll tell you, Sam, I'm here all day
for you if you wanna talk about different
techniques. You know, there's box breathing. There is
reframing.
There's so many different things that you can
do in the moment, but let's just do
two. One of you, this one and another
one if that's alright with you. Yeah. Okay.
Imagine
that you're on a boat out in the
water, and all of a sudden,
a storm comes up.
Your boat is getting tossed around.
So you have a couple choices.
You can scream at the storm and tell
it not to happen.
You can ignore it and let the storm
bat your boat around. Storm's still gonna be
there.
Or you can
look for a safe harbor.
Steer your boat towards there.
Drop anchor
until the storm
calms down. Storm's still gonna rage.
Can I drop anchor
and settle?
So this technique,
it's called dropping anchor. And this was originally
developed in acceptance commitment therapy. And it's probably
one of the most evidence based tools
that applies to emergency medicine. There are many
of them, but I don't know. There's, like,
5,000
articles on that. I think it truly 5,000
articles is. So how do you drop
and settle
in these moments?
And it's twofold.
It's naming and noting.
Let me
name
what I am feeling right now.
What is the somatic sensation that I have?
What do I feel in my body? Do
I feel heart racing, heart thrumming,
a tightness? Is my jaw clenched?
Let me name that physical sensation.
Name it.
Alright.
Let me note
what I am thinking.
What is my emotion?
And what that means is changing fact.
This is horrible.
I say this is horrible.
That is a fact. Two,
I notice I have the thought that this
is horrible.
It's taking a half step back
and noticing what your mind is doing. Because,
Sarmaid, you know, you and I know a
thought's just a thought
until
that thought takes over and completely controls your
emotive state in your physiology.
Naming and noting
allows
a hair of psychological
distance
from
all of this tumult that may be taking
over.
And along with this,
you can just bring yourself back to what
is happening right now. Hope. I'm in the
Recess Bay
doing CPR.
Here I am right now.
Rather than going back, going forward, ruminating.
Anchor in the moment. And this does two
things, and I'll explain these terms. So it
grounds you, and that's not grounding in some
kind of woo woo way.
It grounds you
to help regulate the autonomic nervous system, and
it prevents
dissociation.
Mhmm.
So grounding,
this is intentionally
connecting to what is happening in the present.
And what we're doing with dropping anchors, we're
doing that through the body, through the senses,
anchoring ourselves to what we're feeling. You know,
are we overwhelmed?
Are we detached? Are we emotionally flooded?
Let me just come back to the present.
These are things we'd often like to run
away from. I don't like that tight feeling
in my chest. I want it to go
away.
Notice it. Welcome it. Here it is. Now
there's much more work to do on this
to build this skill,
but when we drop anchor,
we ground ourselves.
We decrease the chance of dissociation.
And when we're talking about,
you know, trauma,
dissociation
is where we become mentally and emotionally detached
from what's happening in the present moment. Like,
we're watching it from the outside. We're emotionally
numb. We're in a fog. And that's not
a horrible thing. Like, this exists for a
reason. It is probably our brain's way of
protecting us when things feel too overwhelming.
And Yeah. In the ED,
Sam, you and I both know that dissociation
can sneak in like a thief in the
night. We start zoning out mid shift. We
feel robotic, and our brains are a little
foggy. So
one tool
for this is
dropping
anchor in the moment. I will pause there,
and then we can, you know, briefly touch
on another tool.
Yeah. I like that. I like that because
I think it takes me, like you said,
one step away from
this whatever this challenging scenario pulls me back,
maybe
engages that other part of my brain that
is, I don't know, more executive in function
to give it a name and to give
it a kinda
to name it and to help
frame it in some way that's a little
healthier than than where I might go otherwise.
I like that.
So some folks might be listening at thinking,
you know what? I'm not on board.
I'm on board with all that stuff.
Sure. So here is an even easier way.
And, yes, a debrief
is
great.
Just
process the emotion, what you felt,
dropping anchor.
Great.
I think the most
basic one of all of these that,
appeals to our
prehistoric brains
is a body oriented reset.
So this is a simple way. After a
case like you had in
the trauma bay,
you know, and everybody wants a PCU,
step outside
if you can.
Mhmm. Look at the horizon.
Shake out your arms.
Shake just shake it out. Shake it out.
Shake it out. Shake it out.
Let your body discharge energy because it's energy.
It's stored up energy.
Just discharge it.
And
this is not strong evidence, but there is
even evidence that sprinting after these events can
help integrate traumatic experiences.
And
these
oriented
resets are used in certain types of trauma
therapy
to prevent trauma from embedding in the nervous
system. That's almost like a hack. And Yeah.
Some trauma
practitioners,
they do recommend
intense
short burst of exercise, like sprints, boxing drills,
some kind of fast paced movement
after a critical event.
Discharge energy.
That can be hard to do. Now running
sprints in your clogs in the ambulance bay
might be hard. Yeah. Yeah. I guess you
could do some squats or or something.
And so easier way is just, you know,
get out, take it out, take a couple
deep breaths. You can stretch or just walk
around a little bit.
It's a a lower barrier
still effective.
I like it. Okay. So name it
and ground yourself in the moment and or
walk outside
and
engage in some active movement while
looking at a horizon or something a little
bit more
calming and a little less stressful than the
tracking board for a few minutes. Yeah. And
don't bring your phone outside.
Oh, yeah. So as you said that, I
wanna bring up one more thing that I
think every emergency doc
would benefit from,
and that is a post
incident
ritual.
I don't know what this looks like for
the individual because it's very individualized
and it can be tiny. And so the
technical term for this would be signal completion.
Because what you're talking about is
you walk out of the room, you are
not complete. You still have an open loop
from that resuscitation. And that's what we're talking
about with all this stuff.
Dropping anchor. Let's reset our body.
A post incident ritual. So, you know, example,
before I walk out of the trauma bay
I well, I think you can see this
on the video. Before I walk out of
the Trauma Bay, I touch the wall,
take a breath, and reset.
And I don't know what's in my mind
or in your mind at that time, but
that's my ritual that I'm closing the loop
on this, or I'm washing my hands. I
am intentionally
visualizing stress
going down the drain.
Two examples of infinity. And what this does
is it helps the brain close the open
loop of
what was previously an unresolved
stressor.
Yeah.
Yeah. I love that. No. I like that
very, very much. I wish that had come
up in my last year of residency
so I could have used it in practice.
That's some great advice. And, you know, I
really do think that the emergency department over
time has become more and more of a
pressure cooker. And we've talked about this before,
you and I, on the podcast. So
this kind of information and these
tactics, I think, become more and more necessary
even in just the day to day shifts.
I mean, so far, we've been talking about
the trauma
of patient experiences. But, honestly, some of my
most traumatizing moments in the emergency department had
to do with conflict with colleagues
and consultants, you know. Arguments I had over
the phone or desperately trying to convince
some specialist that the patient critically needed their
intervention
or that they needed to come in in
the middle of the night and having some
very uncomfortable
conversations that, you know, sometimes it was less
traumatizing
to talk to a patient than it was
to talk to a consultant. So it's not
necessarily
a trauma
in the ED sense that brings about the
scenario. It could be a patient encounter, a
call with a colleague, any one of those
things. And then I also like that you
said, you know, there's a difference between debriefing
and just ruminating on a specific
encounter because I'm expert at that. I have
a advanced degree, a PhD in the rumination
and the reliving of the moment. That's not
something I recommend. You know, if you can
avoid that degree, I highly highly recommend it.
But that's something that comes back to haunt
me. Even now, I can look back on
conversations I've had, you know, over a decade
ago and relive them in a heartbeat or,
you know, when I'm watching medical dramas on
TV or seeing dramatizations of physicians having experiences,
sometimes I just can't watch. I go, nope.
This is reminding me too much of an
encounter I actually had.
When I'm talking with docs about this stuff
and, you you know, you're talking about the
locked room for the giant stuff sack.
Yeah. We have been talking about these big
t trauma events
and
these things that just seem to have this
massive footprint.
Ninety nine percent of the time, it is
accumulation of those lowercase
t traumas, such as incivility from a colleague
or something with a patient. These things that
are small
yet accumulate
accumulate accumulate, and those are the things that
we stuff into that stuff stack. Oh, god.
Again
again, I had to have this argument. And
you feel it, you know, even just even
I'm saying it right now. I'm picturing. I
can still feel it physically.
And that stuff
needs
processing
and attention
because it will accumulate and is way more
likely to burn you out
than
the mass casualty you see once in your
career.
Yeah.
And so in that processing so you've got
the in the moment
event
you've got the in the moment activities you
can perform. You've got the post moment activities
you can perform. You've got your
driveway debrief that you can perform.
And then
with the failure of all of those things,
then you certainly have other resources. Right? I
mean, you can seek out
therapy or trauma therapy or other resources
outside and away from work to try and
deal with those things
in order to either prevent
or treat the repercussions
of just our routine work. Right? So you
can tackle it from all angles.
I did not do this, but I think
that every emergency doc would benefit
from having a therapist
who specializes in stuff like this. I'm not
talking about a general therapist, but a trauma
therapist
Yeah.
From day one
of residency.
It maybe adds up a cost, but being
able to work on this stuff
will extend your career and just help you
process the stuff. Just help you process all
of this that comes at you in this
supranormal
environment.
Mhmm. And I'm saying, hey. Therapy. Therapy. Therapy
is the answer. Okay. Well, maybe it's not
a therapist, but at least a system of
how you're gonna do this. And, you know,
we're talking about the difficult consultant and all
that. Having
an approach to things
is going to be better than not having
an approach. So when there are things that
stress you out, such as a critical neonate
or a mass casualty or incivility from a
colleague,
building up pathways
and
having the confidence that you know what to
do in these situations
is going to serve you from a
trauma standpoint that, you know, how you frame
it in the moment. The story put that,
oh, I can navigate this. You know? What
this joker, I can handle this versus, oh
my gosh, there's gonna be conflict, and I'm
gonna feel like an idiot. And all this
toxic the inmate comes in. I got this.
I know what to do. These are sick
patients, but I'm prepared versus I am unprepared.
Being prepared, having pathways,
that in and of itself
is protective.
Yeah. Yeah. That's a great point. You know,
I never ever in my career thought that
having a
pathway
for how to deal with a resistant consultant
would have been something I needed. But absolutely,
that would have made so much of my
practice easier
to have that, you know, the little button
you push go. Oh, this person's being difficult.
I'll just push this button, and I'm gonna
walk down this road of questions.
I see you don't want to come in
in the middle of the night.
Let's talk about why I'm calling. And then,
you know, answer yes, answer no, answer no.
Okay.
Yes. I can see why you have understood
it to be that case. However,
let me go back to the patient that
I am talking about. You know, it would
have been so much easier to be like,
I need a call center script for how
to deal with this consultant in the middle
of the night. Would have made my life
so much easier. Okay. To that point, and
it's gonna sound like a shameless plug, but
I have to put in the context of
story. Every
cohort of Unburnable, this happens. What you're talking
about, we have basically a month on
navigating difficult consultant and communications,
and it's about this stuff.
And what happens is a lot of docs
this is the thing that brings misery to
their career. And then they've learned these tools,
and they can't
wait
that doc
to start giving a bunch of crap.
And they're waiting
like a panther
in the night
to pounce and not pounce in a bad
way to say, oh, I'm gonna shove it
right back in your face, but, oh my
gosh. I can see what a joke this
is, what a joker you are with these
things. And, you know, this is
compassionately towards the other person, but I'm so
excited to be able to deploy these tools.
And you think about that, Sarmad, and just
apply that to anything that you do in
medicine that,
oh, I'm so excited to deploy this tool
of communication,
of I know how to get vascular access
on this critical patient.
I'm excited versus
I freaking
read this is about to happen.
Woah. How different are those careers?
Yeah. Yeah. That's incredible.
That is incredible. Alright. Tell me the name
of the course and where someone can go
to learn more. Okay. So when you find
all my stuff at RobOrman.com,
that's one on one coaching. That's the unburnable
course. Unburnableunburnablecourse.com,
or or you can just go on my
website. There's lots of different places to find
it. And we've got a podcast and lots
of free resources specifically for emergency docs to
address pain points that come up in clinical
practice.
Absolutely.
And those links will be in the show
notes. There is so much more we could
say on this topic. But if you're listening
and you work in the emergency department, I
just want you to know that much like
your continuing medical education fills in your knowledge
gaps for treating patients, you need something
in this
area
to complete your practice and your knowledge so
that it will encourage your career to be
as long and as fulfilling and as joyful
as it potentially can be and prevent that
burnout. Or
as I tried to explain this to my
teenage daughter, what it's like to invite someone
into your massive mansion of a home and
say, hey, welcome. Come inside. And then the
person walks into a room that looks like
a small bathroom with some white walls and
a window. And they go, where where is
the rest of the house? I mean, this
place is a mansion. Why am I standing
in this teeny little room? And I go,
oh, this is where I live. And they'll
say, well, what's behind that door? And I
go, oh,
yeah. I've been cramming stuff in there
for decades. There's no space left in the
rest of the house. So I live here
in this little room.
So if you wanna enjoy
your house and your home and all of
the spaces that you are supposed to have
for the long, long life that I hope
you live, then you need to have these
skills.
And I'm happy today that there's a place
you can go to get them, and there's
always other resources out there. So devote a
little to talk to some colleagues.
Go to roborman.com
and take a look at the resources. But
do yourself a favor and partake in those
things as soon as possible.
I love that metaphor, Sam. You told me
that before we were recording, and just picturing
you standing with your arms at your side
with no room to move around. That's right.
It's fine. That's what it's like. Welcome to
my mansion. Welcome to my mansion, my castle.
Wait. Why are we in this room? This
tiny little place. I'm sorry. The rest of
it is just jam packed to stuff I've
been cramming in there for years.
Oh, my goodness. Well, doctor Rob Orman, thank
you so much for being on the podcast.
Once again, the contributions are so enlightening and
so important and so career transforming. If you're
listening, again, I can't recommend it highly enough.
Go check it out, robwormon.com.
Rob, thank you so much for being on
the show. Always a treat, my friend.
Well, ladies and gentlemen, that's the end of
today's episode. Thank you for joining us. Don't
forget about ebmedicine.net,
your one stop shop for all of your
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as always, on the website ebmedicine.net.
Until next time, be safe everyone.