My first day on the trauma service was my worst day of intern year. Our trauma rotation was a 24 hour shift, 24 hours on, 24 off. It took place at a large urban academic level 1 center also known as “the College.”. My first shift fell on Fourth of July weekend. Up until 10 pm things were good. The first few patients we saw as a team – mostly injuries from car accidents requiring X-rays or CT scans. Nights at the College were legendary among residents but so far I didn’t see what all the hullabaloo was about.
When the clock struck 11:30 pm, the flood gates of the city opened, sending waves of patients through the doors of “the College.” By 12:30 am, we were full and I was praying to God that some Radiology residency somewhere needed a new intern. I went to see my first patient, a 15 year old brought in by EMS for a facial laceration. She was sitting on the bed, arms folded and not interested in any of my questions. Her equally young friend was bouncing around her bed, telling me her friend needed help now. The friend offered that they were at a barbecue when someone started a fight with a boxcutter. “NO!” they didn’t want the police called and “NO!” they didn’t know where her parents were. We had about 10 patients from the same incident so that part about the parents was probably true.
I removed the bandage on her face. The patient had a 3cm laceration on her left cheek, with some muscle involvement, but the bleeding was controlled. I replaced the gauze and went to debrief my senior residents about the patient and my plan to call Plastics. I was informed that Plastics was seeing patients in the department, but would be tied up for a while. My resident looked at the wound, told me “You can handle it.” My jaw dropping was probably not reassuring but I tried my best to explain to the patient the next steps. After the word “needle,” she and her friend started to argue about said needle, not hearing much else.
“I don’t want a needle”
“But you need to get your face fixed.”
“I’m not getting a needle.”
“Girl, go on and get this done so we can go.”
Five exchanges later, I interrupted them. I talked her through the plan and if left alone, the scar would be so ugly on a very pretty girl. No dice. I tell her the needle is small and once the cut is numb, she won’t feel the stitches.
“Needle? Stitches? H@ll NO!” Followed by a rapid stream of curse words.
I explained again about the numbing medicine and walked away to get supplies before she could restart the stream of curse words again. When I returned, she and her friend were still arguing but she finally agreed to be treated. After cleaning her face, I drew up the lidocaine and approached the wound with the needle. Before I could start, the patient jumped off the stretcher and ran out the trauma doors. Her friend broke into a sprint right behind her. I was left standing in the middle of the hall, needle in hand. My jaw dropped again, in disbelief of losing my first patient one week into this doctor thing. What would my team say? I bet this doesn’t happen in dermatology.
A few years wiser, I now walk into a busy shift bracing myself for the worst. Sometimes it’s a great day and I feel like Keanu in the Matrix, deftly dodging negative forces attacking my ability to treat patients. On these days, myself and my team of providers and staff run the board looking at chief complaints to figure out a plan to clear out the department or at least try not to leave it a hot mess for the next shift. In emergency rooms nationwide, we examine and treat over 100 million of patients each year to the point where, good or horrible, these are normal days for us. Sometimes we forget our everyday normal is extremely abnormal for most people. Our departments are loud, scary and get chaotic quickly. Our patients are often in pain and confused about what is happening to them. Keeping that perspective may help us connect quicker with patients and allow us to get our job done.
We also need to consider how this type of environment affects us as providers. Noise, interruptions and lack of adequate staffing are daily challenges we face while providing quality care. Compassion fatigue and provider burnout are all the rage now in workforce research. Health systems, residency programs and provider owned groups have been at the forefront of patient satisfaction initiatives. This same attention needs to be paid to provider health and well-being to ensure there are enough practitioners to treat patients. Meditation rooms, mindfulness breaks or friendly visits from administrators or ministry staff during a shift may help elevate some of the daily stress we experience. The same care we strive to extend to the patient experience should be given to all workers caring for patients to combat fatigue and provider turnover.