“Trauma Alert. Thirty-three year old female, multiple gunshot wounds, vital signs stable. ETA five minutes.”
One of these announcements over the Presby emergency department PA system sets into motion a decisive and consistent protocol that I became familiar with during my clerkship rotation on trauma. I join an assembly of nurses, techs, residents, and fellows at one of the empty stretchers in the trauma bay, ready for whatever rolls through the double doors. We are often told as physicians in training that you can assess a lot about a patient just by what you see. In the first five seconds after the patient comes into view, on a gurney flanked by EMS, we discern whether the patient is moving or still, moaning in pain or silent, visibly bleeding or possibly concealing something more occult. What a patient’s arrival doesn’t announce on sight, the team will find on primary and secondary surveys or CT imaging. The truth comes out one way or another.
Part of the truth-telling are the vital signs, the numbers that don’t lie: blood pressure, heart rate, oxygen saturation. A patient screaming out in pain with a blood pressure of 130/80 may not be in as imminent danger as the patient steeling themselves to be stoic with a blood pressure of 90/50.
Next, the primary and secondary surveys are standardized head-to-toe inspections always performed the same way, no matter the level of suspicion of injury. In the milieu of the trauma bay, I hear the survey leader calling out physical exam findings–“Bilateral breath sounds,” “GCS 15.” The patient gets dissected into these data points that create a clinical picture of sick vs. not sick. With each discovery of a pertinent positive or negative, the picture is filled in with more data that informs decision-making.
In this necessarily systematic and task-oriented environment, there are rules. If you’re not contributing an essential role, step behind the red line. As a medical student, I know now is not the time to ask questions. In critical moments, the goal is to maximize efficiency and minimize waste. But sometimes a wrench gets thrown into this well-oiled machine.
A patient arrives–a woman in her 30s who had suffered a gunshot wound to her leg. Laying on the stretcher, she is restless from the pain, writhing, flailing, and unable to stay still. This is making it difficult for the staff to put the monitor leads on her chest, hold her arms steady to take her blood pressure and place an IV, or any of the other vital tasks they need to do. In her pain, the patient is repeatedly crying out for help. The team tries to ask her to hold still, but she seems too distracted in her pain. Finally, someone speaks up–
“We aren’t the ones who shot you! We’re trying to help you, okay?!”
I would hear several variations of this comment during my month in the trauma bay. “You need to get a grip” to another patient constantly yelling in pain from a gunshot wound. Complaining behind a patient’s back that they were “whining like a child.” Ultimately, the same message was delivered: “Tough it up. Get with the program.”
On the one hand, I understand where this message comes from. Volume needs to be controlled in the trauma bay so the survey leader can be heard while announcing important findings. They need to minimize distraction so they can assess patients and expedite life-or-death decisions. On the other hand, I would feel grossly out of place criticizing a patient who had just been shot for “overreacting” to such an excruciating experience that must consume all of their senses. Some of these patients in physical and emotional distress are perceived as “out of control” in an environment that has zero tolerance for drama.
It goes without saying that there is also incredible compassion that takes place in the trauma bay. Lives are literally saved. Space is made for moments of silence when patients pass. Trauma surgeons advocate for their patients in the hospital and for violence prevention in the community. There is a necessary perseverance and even optimism in this profession where healthcare workers often feel like they’re doing damage control, and the burden of death and disability is unrelenting. However, my experience witnessing the other side of these interactions made me curious about how people cope in these high-acuity professions, especially as I plan to apply into emergency medicine this year.
Outside of the Presby trauma bay, burnout is a significant problem among healthcare workers. Burnout is described as physical and emotional exhaustion, a decreased sense of personal accomplishment, and depersonalization. Some studies state up to half of physicians experience burnout, with trauma surgeons being one of the highest risk specialties. There are unique stressors to working in trauma, including caring for patients in critical and unpredictable conditions and witnessing the sudden and destructive effects of violence. This can manifest in negative attitudes and behaviors like cynicism and indifference towards patients, coworkers, and even ourselves. The detachment that is necessary when dissecting a patient’s vital signs and physical exam becomes maladaptive and pervasive. After repeatedly seeing people on their worst days, burnout can settle in while empathy falls through the cracks.
Interestingly, empathy–the ability to understand someone’s feelings in their experience–has a controversial association with burnout. Some studies suggest that having high empathy predisposes to the emotional depletion of burnout, as if empathy is a nonrenewable resource that can run out if we give too much. However, another systematic review of ten studies among healthcare workers showed a consistent inverse relationship between burnout and empathy. As burnout increases, empathy decreases–consistent with the definition of burnout. The food for thought is that the converse–as empathy increases, burnout decreases–could be plausible as well. Another study proposed a model demonstrating empathy as a protective factor against burnout with the nuance that sympathy and empathy are two distinct concepts. The authors defined sympathy as sharing someone’s feelings as if they were yours, attributing their perspectives to your own. This would feel like experiencing pain and suffering along with your patient, which could likely cause emotional exhaustion. On the other hand, they defined empathy as understanding how someone feels in their own perspective, traveling from your point of view to theirs without merging or isolating the two. This would be like understanding the inner state of your patient and knowing how it feels like to be in their shoes while still being aware that you are in yours. They described that this kind of empathy seems to prevent the development of burnout
Burnout is a multifactorial problem that can’t be patched over with a simple remedy. And empathy is just as complex of an idea. On busy days, when the trauma bay or the emergency department feels like a revolving door, it is easy to imagine that triaging and assessing and discharging will crowd out empathy from the forefront of our minds.
In the early evening of a shift towards the end of my rotation, another patient was brought in by ambulance. Once again, I saw EMS roll the gurney through the double doors to trauma bay two. My eyes scanned the patient on the stretcher. He had been in a motorcycle accident and was unresponsive, with an open tibia-fibula fracture protruding from his left leg. He was in significant pain as we rolled him to each side assessing for other injuries, with team members holding his injured leg to immobilize it. As the patient received volume resuscitation, he began to have pulsatile arterial bleeding from the leg, prompting a STAT call to vascular surgery. Ultimately, he was stabilized and transferred to the trauma ICU.
The next morning, the patient was presented during rounds to a room of new people who had not been in the bay when the patient first arrived. From further investigation, the story emerged that the patient had stolen the motorcycle, then crashed it in an intersection. There were some laughs from the room, in an “Are you kidding me?” kind of way. As in, “Of course living life like Grand Theft Auto doesn’t have a happy ending.” Unexpectedly, the attending trauma surgeon interjected–“You know, I don’t know what this person has gone through in life to be at the point where you end up like that, stealing a motorcycle. I’m sure he didn’t grow up thinking he was going to be in this situation.” The tone in the room changed. The attending hadn’t offered a soapbox or condemnation, just a humble reminder to look for a person’s humanity when it’s difficult to see. It was a moment of perspective that underscored the patient’s right to their dignity, even as a character in the narratives we tell ourselves.
That moment stands out to me, now several months after the fact. I had great respect for that trauma surgeon before this comment, and I am even more appreciative of him afterwards. More than just an isolated remark, it showed me an example of empathy in real practice: trying to understand someone in their own circumstances, regardless of whether they can “tough it up” to our standards. It is a decision we can all make to be generous in giving people the benefit of the doubt, rather than placing blame. Looking forward to the years of training I may undergo as an emergency physician, I want to be cognitively adept at evaluating patients’ clinical conditions and utilizing technical skills to manage their care. I also hope that when I am feeling exhausted or frustrated in this field of alleviating human suffering, I can remember to live with humility and curiosity about the people around me. It is not a foolproof way to sustain a strained medical system, but a moment of empathy in my perspective will bring me clarity in the midst of heaviness.
Justine Wang is an MS3 at the Perelman School of Medicine.
Art by Adina Singer, an MS1 at the Perelman School of Medicine.
