Today, I present an excerpt from an interview with Andrew Davies, host of the mastering intensive care podcast. The full interview was over an hour long, but this is a polarizing excerpt.
The Full Mastering Intensive Care Interview
REANIMATE 7 Conference
Additional New Information
More on EMCrit
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
I think there needs to be a separation of person and provider in some circumstances. I think it’s a mental defense reflex for the provider as well. This mostly applies when the patient is in a critical situation and you have a number of invasive procedures to do in order to help. If I didn’t separate out the person from the patient, I don’t know that I could do these procedures to the person. The example for this, would be something like an Intubation. In any other circumstance, placing a long hard tube into someones wind pipe isn’t really acceptable… Read more »
William Osler said similar things: “Acquire the art of detachment, the virtue of method, and the quality of thoroughness, but above all the grace of humility” “Now a certain measure of insensibility is not only an advantage, but a positive necessity in the exercise of a calm judgment, and in carrying out delicate operations. Keen sensibility is doubtless a virtue of high order, when it does not interfere with steadiness of hand or coolness of nerve; but for the practitioner in his working-day world, a callousness which thinks only of the good to be effected, and goes ahead regardless of… Read more »
This is totally true. If you are ever in doubt about that invisible mental switching your brain has do a 12 lead on your wife. I have done a 12 lead on my wife. It hurts your brain. Because you’re in your ambulance and so you are a provider. And you go to put on the 12 lead and your brain crashes because those are mine. She is my beautiful bride. I said I do and made a lifelong commitment. And your brain just totally hurts and it crashes it’s like the windows blue screen of death. Because your brain… Read more »
I agree as a former ED nurse for many years that there needs to be some kind of separation. I often called it “compartmentalizing” when I was dealing with those trauma or critically ill patients during the initial resuscitation. My career in emergency medicine would not have lasted the 16 years that it did had I not been able to “flip” that switch when I needed to. A good clinician, be it RN or MD is able to make that transition without conscious thought allowing them to do the job necessary and once the patient is stabilized they are able… Read more »
Joel Feltner HealthTeam CCT West Virginia I get what you’re saying. 25yrs as a medic. I tell folks that you kinda get in the mindset that you are a “people mechanic” during a resuscitation. Their body is “broke” and you have the “knowledge and tools” to fix it. I think the easiest test to check someone’s “flipping the switch” is to ask what color eyes the patient had. Any time I had a problem “flipping the switch” (usually on a kid) their eye color always stood out. The ones that haunt me, I remember their eye color. The horrible calls… Read more »
Very interesting subject ! I am not sure there is such thing as to be People-Oriented in the midst of resuscitation (We talk realllly sick here..). We all “Flip the switch” to transform the patient in a puzzle that we need to solve, with critical steps and checklist to specific endpoints. I think we need a clear mind to process information, perform critical task and this is not compatible with reflecting emotionally on the case. You seemed to feel bad Scott about how it sound to say that you are “Care-Oriented” and you shouldn’t. I think there is no link… Read more »
Former critical care nurse, current FNP and paramedic- I’ve seen lots of resuscitation and most recently saw my 3 year old granddaughter. critically ill, septic, and needing ECMO. I definitely saw the separation between staff seeing her as a patient vs a child. Frankly, I am very thankful for all the staff who saw her as a patient. I could not have been as aggressive in providing her care, even though I knew everything they were doing and had done it myself many times. She was my grandchild, she was their patient, and that made all the difference. After over… Read more »
I completely agree that we have to flip a switch. I also think that we owe it to the patient to flip that switch, leave any emotion out in the hall, and go to work on pathophys. Flipping this switch back when we are in control is where it gets tricky. Sometimes I take a little too long…
Hi Scott! I agree with you!
Totally agree. To do the job well, you need a transient disconnect. As a further analogy I would say this, kindness, compassion and a bedside manner are great, but if someone is going to cut into me, I just want the one with mad skills. If he/she just grunts afterwards, I’ll just say thanks!
Fine. Be that way. You get The Sternal Rub! I realized in listening to this podcast that my “switch,” that takes someone from Person to Patient, is to pretend that they are openly challenging me. The best example in my practice is the sternal rub. I would NEVER do that to a conscious person, yet someone I’ve never met rolls into the ED unresponsive, and within 15 seconds I am “assaulting” them. In my mind, I pretend: this patient is silently inviting or even challenging me to fix the problem, and seems to have recruited a bunch of bystanders to… Read more »
As an RN in the ED, I completely agree with you about the switch in mentality that occurs with those patients who are trying to die. In that moment they are not people, they are broken machines. We scissor strip and expose them, poke holes in them, and drill into their bones to obtain access. We do this because in these critical moments both time and mental focus are finite resources that must be allocated in a way that is most beneficial to the patient. Notice, however, that I said I am a nurse. Yep, the nurses in the room… Read more »
Hey Amanda,
Think I was pretty clear when I discussed this that I was talking about crit care nurses in the ICU as opposed to ED nurses doing resus. For better or worse, the ED nurses are right there with the ED docs in needing a resus mindset.
Really great conversation that focused my thinking about something that we do automatically in resuscitation.without even realising it.
As an intensive care paramedic in the prehospital setting I certainly focus on treatment while in resuscitation and not on the patients humanity, but trying to keep them alive if that is appropriate but then when stabilised then you switch back onto them as a person.
Had not even thought about it previously.
Thanks and keep up the great work.
I would filter my response for many, but I believe you to be someone who can not only take, but on some level appreciate, the unfiltered version. Horseshit. I don’t think you ever have to make a “person” a “patient” (as if those 2 things are in any way separable) & “forget” that patient has a life & interests & people who love them in order to aggressively resuscitate them. As you mentioned, probably the hardest is children. Then entire time I am running a peds recuss I am hyperfocused on the it, but also am acutely aware of that… Read more »
According to you it is just the docs who are afforded the luxury of compartmentalizing during a resuscitation… focusing on delivering high quality care while nurses should remain empathetic always. Interesting that the example given of turning a “person” into a “patient” was placement of a Foley cath. Never have I ever seen a doc place a Foley during resuscitation. It comes across as a bit sexist – the caring nurse holding the patient’s hand while the macho doctor is busy saving his life.
Jen, The ONLY way the discussion could be construed that way is if in your belief structure doctors are male and nurse are female. This is distinctly not the situation where I work and this outdated gender structure whether actual or merely implicit in your worldview may be why you heard what you thought you did. Come visit and I am happy to show you doc foley placements.
Hi Scott Very interesting chat. Brave to acknowledge your psychological “switching” to a more robotic / clinical mindset…. this is a ubiquitous phenomenon and one that is crucial to allow human brains to function in moments of stress. We all do it! I did a ton of reading and research on this to prepare for my Smacc Gold talk way back in 2014…. link below https://broomedocs.com/2014/09/the-history-of-empathy-from-smacc-gold/ Empathy is a hard wired human neurological state. We can transiently suppress it with exposure and training. The research by Decety et al shows doctors (and nurses, ambos etc…. anyone who deals with people… Read more »
Hi Scott,
I totally agree with this thought of changing the mindset of what is front of you. I do this regularly on critical calls. I feel that it gives the best care and also provides the Provider the best longevity for this career.
As always, the podcast is appreciated.
Eric
I too have reflected on the “indignity” of resuscitation. For me this is particularly poignant when it comes to family presence during resuscitation and discussions of end-of-life care (goals of care). As an ED RN, I too find it necessary to compartmentalize and focus on the “patient” and not the “person” during resuscitation. I also think it may be easier to compartmentalize in a hospital environment – the ED is the place where I expect “bad things to happen.” I am curious if our pre-hospital colleagues have a more difficult time compartmentalizing or at least processing traumatic resuscitation after the… Read more »
In hindsight I am uncomfortable with the word “de-humanize”…poor word selection. Apologies
I think you are completely right on resuscitation mindset. Without that separation I can’t see how we could function in resuscitation and maintain sanity for long. I think we tend to look at them as a series of problems to be solved, solve those problems and maybe they live. and go back to being an individual human in our minds. Empathic connection to people we know are likely to die seems dangerous, it can cause us to lose focus and fail our patient, and ultimately it can be what brings us the “moral injury” we probably all suffer from eventually.… Read more »
I just listened to this podcast and I can’t agree more to the distinction of patient vs. personhood. It’s the first time I have heard someone put a binary point between these two terms. I have always thought a person is a patient but in your description, there is a time when a person is completely a patient, during resuscitation. This to me verifies my observation of ICU docs who go into this mental switch during a code or when a patient is rapidly deteriorating. Nonetheless, in your experience, how long do you switch back into seeing a patient as… Read more »
think as soon as the resus period ends, we start to move more towards personhood. Looks very similiar to the overlapping triangles of curative and palliative care
Scott – thanks for your honest reflections here. I’ve absolutely felt this detachment flip on and off, and have struggled with the challenge of emotionally coping with doing ED resuscitation. Another way of framing this is “how do we protect ourselves from the secondary traumatic stress that is witnessing human suffering in resuscitation?” This is a huge challenge across healthcare fields and professions. The high rates of PTSD in EMS, Emergency Medicine, and Emergency Nursing clue us in to the challenges we all face in coping with occupational exposure to secondary traumatic stress. I fully reject the false binary of… Read more »
Thanks for posting!
I feel somewhat related would involve procedures or surgeries …in general.
Why are drapes opaque and not clear?
I really enjoy your show, great work. On this subject though I cannot disagree more. I believe that you provide care better when you connect to your patient as a human being. I believe above all, dignity and humanity come first, even if it is just for a brief moment before we get to work. Taking a brief moment to connect with your patient. I honestly do it as part of my initial impression. I stop , remove bias, connect emotionally then get to work, takes like a second. Sometimes it is just saying or thinking we are going to… Read more »