The Ripple Effect of Mass Shootings

Typically, after a mass casualty event, an array of reporters line themselves outside a hospital, using our walls as the backdrop to their stories.  Then, a press conference is held, during which, at some point, a surgeon will stand behind a pile of microphones, wearing clean scrubs and a pressed white coat describing the “how many’s”… How many patients, how many surgeries, how many injuries.  Those numbers, however, are only a fraction of the real story that has occurred behind those walls of that backdrop.

This is the rest.

As trauma surgeons at Level 1 (meaning the highest level of capability) trauma centers, we are typically notified immediately after our law enforcement colleagues about an “active shooter situation”… before much or anything is actually known.  And while the situation is evolving, then, the wait, the anxious anticipation, and the questions begin.

Resources are assessed.  How many trauma surgeons are in-house (meaning in the hospital)?  How many operating rooms have patients in them already?  All open operating rooms are kept that way, explanations given to patients whose surgeries are held, with the barest of information possible.  All to allow for as many available operating rooms as possible for as many injured patients as needed.  The beds in the emergency department are reviewed – how many empty, how many full, where can we move our current stable patients?  How many ICU beds do we have available for the critically injured?  The blood bank is notified, as large quantities of blood may be needed.  Triage areas are established for patients who come in cars instead of ambulances. Where will parents and family members be kept … waiting to find out if their child or loved one is there, and if so, what has happened to them?  The Emergency Department becomes a hub, the center of a hive buzzing with energy, anxiety, and, most of all, determination.

The waiting happens, with minds and muscles tensed.  You get information… slowly… piecemeal… a bit at a time… some of it correct, some of it not.  The exact location. The number of people injured. The number of ambulances dispatched.

And then, the real crux.  How many ambulances return, and are they full or empty?

After all, what is worse?  Needing 10 ambulances or none… because they are all dead?  What is worse?  Having to witness moments you will never forget or never having the chance to change the outcome?

And when those 10 ambulances arrive, you hope… even knowing the high price to travel that road… a toll your soul will gladly pay… all for the chance, to save even one.

Those patients are unloaded and evaluated – all under the pressure of time.

Every second loudly making its presence known inside your head.

 

Tick.

Tick.

Tick.

 

Everyone’s eyes turn to you – wanting to help, wanting to be helpful, wanting to give this person another day.

 

Be quick, be efficient, be clear.

Be orderly, be organized, be thorough.

Be decisive.

This one needs surgery.  This one doesn’t.

This person can be saved.  This one can’t.

The lines are put in, the tubes placed, the blood transfused, and the surgeries performed.

Patients are identified, families are found, and families are told.

All amidst a visual and auditory cacophony of blood, pain, cries for help, and tears of sorrow.  All images and sounds that can’t be processed now, but will be remembered forever.

And no one will be the same again… now a witness to that which we cannot unsee.

 

The surgeon you see behind that pile of microphones is not the same surgeon who walked into the hospital that morning.

The nurses who get in their car after work are not the same nurses who drove that car into work.

The environmental workers who mopped the floors, wiped down the walls… they erase the evidence of death and pain from the rooms, but not their hearts.

No one is the same.  The EMTs, the ER physicians, the anesthesiologists, the radiologists, the nurses, the techs… all changed.  Imprinted.  Invisibly but palpably altered.

We aren’t represented in the numbers, the statistics that make the headlines.  We are the invisible ripples, all created from the stones forcibly and uncontrollably thrown into our waters.

The next time you hear about another mass shooting, and your heart aches for the injured and the families, please let it ache a bit more… for us.  Because we are still here, ready and waiting… to do it all again.

The truth about the hardest part of my job

I get asked a lot of questions about my job.  Simply stated, when asked “What do you do?”, my response, “I’m a trauma surgeon” is often a conversation starter and questions quickly ensue.

 

“Do you work in the ER?”

 

“What kind of surgeries do you do?”

 

“What’s the coolest thing you’ve ever seen?”

 

“Do you see a lot of gunshot wounds?”

 

And so on and so forth.

 

And in general, I try to be as open and informative as possible.

 

There is one question, however, that is often asked and rarely truly answered.

 

“What is the hardest part of your job?”

 

Admittedly, as much as I love my job, there are some seemingly glaring downsides.  I never really know what I am going to do any given day.  I work long hours…. like, really long hours.  Like, think long hours then double it.  I work days, nights, weekends, holidays, and birthdays without any regularity or consistency.  My job is intense, stressful, and I am a first-hand witness to the destruction human beings inflict not only on each other, but also on themselves.

 

But none of these are the worst part of my job.

 

When someone dies from a traumatic injury… well, for lack of a better word, it’s traumatic.  It is sudden.  It is unexpected.  It is unforeseen.  They woke up that morning, put on their socks and shoes, and walked out of their home… never realizing they would never see home again.

 

When someone dies from a traumatic injury – they are brought into the hospital, and we try to save them.  We place tubes, we place lines, we perform surgeries.  But this flurry of activity isn’t just occurring inside my operating room.  Outside of these sterile walls, police are attempting to identify the patient, then the next of kin, then get in contact with the next of kin, whom are typically told some version of what maybe caused the injury, and the family come flying into the hospital – scared, hopeful, sometimes in groups, sometimes alone and always unknowing.  They have no idea what type or severity of injuries their loved ones has, because all of this occurs typically simultaneous with me diagnosing, treating, and operating on those injuries.

 

When my patient dies, after I am unable to save my patient, I call the time of death. Then, I call our social worker to see if family has been found, and if so, to find out where they are.  They are then brought to a room… still anxious, still nervous, still unsure of what has happened or what is happening. They wait to talk to “the surgeon”.  They wait with questions, thoughts, and words crowding their brains, reassuring themselves that whatever it is, it just can’t be that bad, their loved one is needed, wanted – they HAVE to be okay.

 

And while they wait, while their brains race, feet pace and hearts ache, yearning for information…I change my scrubs, wash my shoes, check my face in the mirror – all to make sure they don’t see the blood of their loved one on me.

 

I then enter that small room where they wait, and their eyes turn to me – full of questions, anxiety, often tears, and always hope. Hope that maybe it isn’t as bad as they have feared. Hope that they can see their loved one soon.  Hope that I am going to tell them everything is going to be okay, their life will be the same… with their loved one in it.

 

My entrance into that room is the worst part of my job.

 

No, it isn’t the actual giving of the words, “I’m sorry your loved one has died”.  It isn’t the watching of tears falling or the listening to the sounds of pure, unadulterated sorrow that follow.  It is actually those moments before I tell them their loved one is dead which give me pain.  Because those moments are pregnant with possibility.  I can see all their hopes and dreams for their loved ones – the birthdays, the hugs, the trips, the children … the time.  I see the time they are so sure they will still have.  I see the time they never imagined not having.  So many possibilities… of all the things I know never will be.  There will be no more birthdays.  No more hugs.  No more words exchanged, memories created, or dreams shared.  My words, in the next few moments, will shatter all of those possibilities.  Those possibilities will be replaced by pain.  That hope will now be denial.  That sense of what life is will be lost… the life they know will be gone… replaced by confusion and bewilderment at the harsh new reality into which my words have forced them.

 

It is the moments before the tears and the anguish that is the worst part of my job.  It is seeing the light in their eyes and having the knowledge that I will be extinguishing that light.  This is what leaves its mark on me.  Because that light represents my patient… who they were, how they loved and how they were loved, all they were… and all they never will be.

 

That is the hardest part of my job.

From Nicotine to Guns: Let Science Speak

How did America go from this?

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To this?

 

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One word: Science.

 

So now how can we go from this?

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Same word. Science.

It is well known smoking cigarettes negatively impacts health and leads to an increased risk of stroke, heart disease, lung cancer and death (https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm).

No one debates this anymore.  But it wasn’t always this way, and it didn’t come easily.

In the 1940’s almost half of the population in the United States smoked, and the tobacco industry was subsequently incredibly powerful and politically active.  It spent millions of dollars on politicians – for their campaigns and the lobbyists used to persuade them.

Continue reading “From Nicotine to Guns: Let Science Speak”

Breaking Down Burnout

Burnout, burnout, burnout.  There is a lot of talk about burnout, which is a good thing.  BUT.  One of the most commonly quoted reasons for burnout I disagree with… It is not just about how many hours we are working.

When you truly enjoy doing something, two things happen:

You don’t really care about how many hours you are doing it and You don’t typically need a whole lot, if any, external validation about it.

For example, I don’t count the minutes I spend with my children (well, okay, except during potty training, and then I’m like, how long is this going to take?!?!?!).  Anyways. I don’t need my husband to give me a pat on my back for spending time with our children.  I do on the other hand, like to get pats on the back for all the mental/administrative work I do for our family – finding the pediatrician, making the pediatrician’s appointments, double checking everyone’s schedules to make sure that the pediatrician’s appointments don’t fall on an operative day, a field trip day, Doughnuts with Dad’s day at school, a full moon, whatever.  Now apply same process to swim lessons, soccer practice, etc, etc.

When you first start in medical school and residency, a lot or even the majority of how you spent your time was in doing things you didn’t necessarily enjoy.  Aka, scut work. Transporting patients, making phone calls, calling consults, writing notes, putting in orders, doing discharge summaries, etc.  Basically, a lot of administrative type duties. Yes, all of these things are important to patient care, but I don’t know too many physicians who go into medicine just because they like writing notes and making phone calls.  However, you did it, because it was supposed to get better… and it did for the physicians and surgeons before us. Although scut work never went away completely, the proportion of time spent in doing did decrease.  The further you progressed in training, and even in your career, there was noticeably more time taking care of patients, more time in the operating room, more time doing procedures, more time at the bedside.

However, this pyramid scheme of medicine – more scut on the bottom, less on the top –  has now become a square.  The administrative tasks, the menial tasks, the unenjoyable paperwork of medicine does not lessen in the same way it did for surgeons and physicians in the generations before us.  Could you imagine asking Halsted to re-do his operative note for the very first mastectomy because it didn’t include his length of incision?  Could you imagine telling Cooley his salary was going to be impacted because he didn’t use the right ICD 10 code in his notes allowing for maximal DRG payments?

DRG’s, RVU’s, CPT’s, ICD-10, Dot phrases, in-baskets, cosigns vs attestations, and emails.  This is how we are now measured.

I don’t count the minutes I spend operating or talking with my patients and their families.  I don’t need a pat on my back for spending extra time with my patients, holding their hand, or performing a successful surgery.  I enjoy and value those things myself.  But let me tell you, I know the exact number of notes in my inbox that I need to complete.  I can tell you how long it takes to get through 100 notes.  I can tell you how many emails I get a day about those 100 notes in my inbox.

Medicine is turning doctors into accountants.

A career in medicine has become about numbers … “metrics”.  How many patients you see in how many hours, how many RVU’s you are generating, how many hours it takes to complete notes, how many addendums are needed to make sure all of the documentation uses the exact right words to equal the right DRG value.

Simply put, doctors don’t want to be accountants.

We didn’t go to medical school because we cared about numbers, because, quite frankly, if you judge a career in medicine solely on the numbers, it doesn’t add up.  The amount of money it takes to apply to medical schools, residencies and fellowships plus the number of hours spent studying for the MCAT, medical school exams, Step 1, step 2, step 2B, step 3, first boards, second boards, recertifications, plus the differences in salaries between what my friends were making after college to me going into debt for medical school then the approximately $13 dollar an hour wage I earned in training, etc etc.

We went into medicine to sit at bedsides, operate, deliver babies… you know, do medical things.

But this is the double whammy.   Physicians spend a huge portion of days (and nights and weekends) doing clerical work because this is what is now required of us AND there is very little to no appreciation for doing it.  When the amount of time sitting in front of a computer equals or exceeds the time we are sitting in front of a patient, THERE IS A PROBLEM.

We are no longer being measured by the kind of medical care we provide.  We are now measured by the documentation, billing, and numbers we provide.

And, the only way to cut back on the clerical work is to cut back on the clinical work.  This is why people want to work fewer hours.  We don’t want to take care of patients any less than the physicians before us.  We want fewer hoops to jump through to actually get to our patients.

Want to help burnout?  Make the computers (ie electronic medical records) work harder, so doctors can work smarter.  Let’s acknowledge that a large portion of the work required by doctors doesn’t involve doctoring.  Let’s create a healthcare system that lets doctors get back to what they are good at…. Taking care of people.

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Jamie Jones Coleman, MD | The Huffington Post

 

 

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Dr. Jamie Coleman – US News & World Report

LinkedInIf only we treated our loved ones like our pets – dying, dignity and death in America by Dr. Jamie Coleman

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