Just work

Abstract

“You should go downstairs to the trauma slot, something about a plane and a building. Multiple traumas expected.” I can't remember his name, or where he was from, just his face and the words he spoke. I had no idea that the words he uttered would forever change my career as a physician and my sense of what it meant to be a New Yorker.I was an emergency medicine resident at New York University Medical Center, working as one of three interns on the largest trauma service in New York City. It was a month that most residents in my programme dreaded, because of the long hours and the intense and sometimes hostile work environment. The service operated more like an infantry unit than a medical team and there was no room for error.I proceeded straight down to the trauma slot (the emergency room area where they receive patients who have suffered from various and generally serious accidents and injuries). Going down the stairs, I thought, no problem, I had dealt with multiple traumas before. In fact, I had just taken care of a triple trauma the night before. As I quickly prepared the trauma area for three or four patients, my pager went off. Another intern on the trauma service urged me to return to the surgical intensive care unit (SICU). An intense, hard working guy who didn't joke around much. He rarely seemed to worry. The inflection in his voice, however, startled me and I quickly made my way back to the SICU. When I arrived he was screaming “Poof, it just crumbled and went up in a ball of smoke. It looked like a big mushroom that exploded!” I was confused. What did he mean? What smoke, what blew up?The southwest view from Belleview Hospital's SICU afforded a spectacular shot of downtown Manhattan—including a nearly unobstructed view of the twin towers of the World Trade Center. After 29 years as a New Yorker, that familiar sight was missing. Both buildings were gone. The apartment in Queens where I spent my childhood, the studio in the Bronx where I lived during medical school, and—until that morning—the view from the SICU at Belleview Hospital, were all familiar places that I equated with New York City and with home. Almost instantaneously I realised the gravity of the situation and felt an overwhelming sense of terror.What was I thinking? Why was I thinking about something as trivial as a view or my own fear? I was on the trauma service, I was a doctor, and I needed to do something. But wait. My best friend's father and his daughter worked in those buildings, my friend from California was in town on business and should have been at a meeting in those buildings. Once again, what was I doing? I was one of only three interns on the trauma service and I needed to work. No time to think. Just work.I took orders from my seniors and did what I was told. I was a robot, discharging patients from the hospital that were still sick to make room for the trauma victims we would soon see coming through the doors. I organised a multitrauma unit with my colleagues in the emergency room, I made sure there was plenty of blood on reserve in the blood bank, and when I tried to call my family on my cell phone, I was quickly scolded and encouraged to keep moving, keep organising, keep doing whatever it was that I was supposed to be doing. In the world of surgery, interns follow orders. So I followed orders. I did not think about what was happening, or why it had happened. I did not have time to think about my family or friends. I just worked. Surely when things calmed down, we would all talk about what was going on, we would have a chance to contact our friends and family members. We were all just too busy to do anything other than work. And that was the right thing to do. Wasn't it?Once the patients started coming in, I was aware of two things: first, there were a lot more patients coming through the trauma area than I was accustomed to; and second, there were several thousand people in those buildings and only one other receiving trauma hospital in downtown Manhattan. Where were the people?As I triaged another patient I was horrified to note he looked like my friend's father. Could it be him? I needed to stop and think, if only for a few seconds, about what this might mean. Within moments I realised that this patient would not make it, and my anxiety grew. As I triaged this patient, who was beyond my help, I looked back one more time. It couldn't be him, this man was too tall, too thin—at least I wanted to believe that. It would be 2 days before I found out that his office had relocated from the twin towers and he would not have been in either building.What a relief, my next patient had a minor dislocated shoulder, could be quickly stabilised, and triaged as non-urgent. But wait, he was crying and screaming. Why was he in such pain from a small dislocation? “I'm so sorry, but I had to go. I had to leave him behind, the building was crumbling on top of us and I just couldn't hold onto him and run fast enough at the same time. He was buried by the rubbish.” I tried to console him, I tried to tell a colleague what happened, and then I realised I was falling behind, spending too much time with this non-critical patient. So, I left the patient crying. I moved on. Just work, I told myself. Just work.Over the next 85 hours, I went home for a total of 10 hours and slept for 3. I heard countless stories from distressed patients—none of which I will ever forget. The most memorable occurred on Sept 12 when a port authority officer made contact on his cell phone and was rescued from the debris. He had severe crush injuries to his legs, and shortly after his emergency surgery I became the physician responsible for monitoring him overnight and making sure he did not die. I checked on him every 30 minutes, adjusted, monitored, and changed things I had only moments before learned how to do. I continued to care for him over the remaining few days I was on the trauma service. The surgeons had performed what I believed to be a miracle. My contribution was so small. His story of rescue was in the papers, his eventual recovery and ability to walk out of the SICU months later made news and even brought the city's Mayor to the hospital. The fear I felt every time I checked on him was only something I knew, and something I never shared with a colleague or with the patient.As we worked, New York University Medical Center received one bomb threat after another. Few of the physicians or staff left the hospital. I sent home every medical student, told them that they were not essential staff and should be with their families. I knew that if any of those bomb threats were real, and if any of those students were injured, I would not be able to live with myself if I survived. I remember the patients, the students, and the hours I worked. In the moments and in the days that followed, I remember only one other doctor asking me how I was doing.On Sept 13, one of the directors in the emergency department asked me “Are you holding up?”. Shocked that it took more than 48 hours for someone to ask me how I was feeling, I said I was holding up. That was the problem. I was well trained to just “do my job”. I didn't have time to think about what I was experiencing. If anything, I was more upset than I was worried, tired, or scared. I was upset about the way dozens of doctors, from various specialties, had reacted to what was going on. I was also amazed that all I heard on the television and radio stations was that the hospitals were empty; the doctors didn't have any patients. Why didn't anyone know what was going on? That I had 40 patients—nothing compared to 5000 victims, but three times as many trauma patients than I had ever taken care of before. Why didn't anyone know that I was one of only three interns on the trauma service in New York City at New York University Medical Center. Most striking, however, was how little my colleagues talked about what was going on, or about how they felt. We were all so good at just working, without question and, sometimes, without feeling.During this event, I experienced what may be the ultimate dilemma in the practice of medicine. We are asked to take care of patients without regard for their moral character, financial status, political beliefs, or personal values. We are asked to work countless hours during emergencies. We are also asked to be kind, sympathetic, and empathetic to our patients. How can we be both impartial and empathetic? How can we care if we are so busy with our “work”?Sept 11, 2001 (9/11) was an extreme example of an emergency. It is not the perfect parallel to the everyday struggles of physicians, but it taught me many lessons early on in my career. Nearly 10 years later, practising as a supervising physician at a medical school in a state geographically removed from the intensity of these events, I am aware that one cannot truly be both impartial and concerned. We are capable of working long and often stressful hours. We are sometimes even able to walk that fine line between providing care, and doing so without question.Although the events of 9/11 may be a distant or purposefully suppressed memory to many, I always remember to ask my students and residents how they are doing or how they are holding up when they are working long hours or breaking bad news to a patient. It is funny how shocked they seem. Almost as if they expect, as I did back in 2001, to be rewarded for their speed, efficiency, and ability to work without question. Just work? Perhaps I did not need 85 hours on the trauma service during 9/11 to realise that the structure under which doctors provide care often renders us limited in our ability to provide care for the patient as a whole. How can we properly care for our patients if we sometimes forget to even think about what we are feeling? How can we feel, if during the most important and stressful of times the “best” approach may be to not feel anything at all? Just work. “You should go downstairs to the trauma slot, something about a plane and a building. Multiple traumas expected.” I can't remember his name, or where he was from, just his face and the words he spoke. I had no idea that the words he uttered would forever change my career as a physician and my sense of what it meant to be a New Yorker. I was an emergency medicine resident at New York University Medical Center, working as one of three interns on the largest trauma service in New York City. It was a month that most residents in my programme dreaded, because of the long hours and the intense and sometimes hostile work environment. The service operated more like an infantry unit than a medical team and there was no room for error. I proceeded straight down to the trauma slot (the emergency room area where they receive patients who have suffered from various and generally serious accidents and injuries). Going down the stairs, I thought, no problem, I had dealt with multiple traumas before. In fact, I had just taken care of a triple trauma the night before. As I quickly prepared the trauma area for three or four patients, my pager went off. Another intern on the trauma service urged me to return to the surgical intensive care unit (SICU). An intense, hard working guy who didn't joke around much. He rarely seemed to worry. The inflection in his voice, however, startled me and I quickly made my way back to the SICU. When I arrived he was screaming “Poof, it just crumbled and went up in a ball of smoke. It looked like a big mushroom that exploded!” I was confused. What did he mean? What smoke, what blew up? The southwest view from Belleview Hospital's SICU afforded a spectacular shot of downtown Manhattan—including a nearly unobstructed view of the twin towers of the World Trade Center. After 29 years as a New Yorker, that familiar sight was missing. Both buildings were gone. The apartment in Queens where I spent my childhood, the studio in the Bronx where I lived during medical school, and—until that morning—the view from the SICU at Belleview Hospital, were all familiar places that I equated with New York City and with home. Almost instantaneously I realised the gravity of the situation and felt an overwhelming sense of terror. What was I thinking? Why was I thinking about something as trivial as a view or my own fear? I was on the trauma service, I was a doctor, and I needed to do something. But wait. My best friend's father and his daughter worked in those buildings, my friend from California was in town on business and should have been at a meeting in those buildings. Once again, what was I doing? I was one of only three interns on the trauma service and I needed to work. No time to think. Just work. I took orders from my seniors and did what I was told. I was a robot, discharging patients from the hospital that were still sick to make room for the trauma victims we would soon see coming through the doors. I organised a multitrauma unit with my colleagues in the emergency room, I made sure there was plenty of blood on reserve in the blood bank, and when I tried to call my family on my cell phone, I was quickly scolded and encouraged to keep moving, keep organising, keep doing whatever it was that I was supposed to be doing. In the world of surgery, interns follow orders. So I followed orders. I did not think about what was happening, or why it had happened. I did not have time to think about my family or friends. I just worked. Surely when things calmed down, we would all talk about what was going on, we would have a chance to contact our friends and family members. We were all just too busy to do anything other than work. And that was the right thing to do. Wasn't it? Once the patients started coming in, I was aware of two things: first, there were a lot more patients coming through the trauma area than I was accustomed to; and second, there were several thousand people in those buildings and only one other receiving trauma hospital in downtown Manhattan. Where were the people? As I triaged another patient I was horrified to note he looked like my friend's father. Could it be him? I needed to stop and think, if only for a few seconds, about what this might mean. Within moments I realised that this patient would not make it, and my anxiety grew. As I triaged this patient, who was beyond my help, I looked back one more time. It couldn't be him, this man was too tall, too thin—at least I wanted to believe that. It would be 2 days before I found out that his office had relocated from the twin towers and he would not have been in either building. What a relief, my next patient had a minor dislocated shoulder, could be quickly stabilised, and triaged as non-urgent. But wait, he was crying and screaming. Why was he in such pain from a small dislocation? “I'm so sorry, but I had to go. I had to leave him behind, the building was crumbling on top of us and I just couldn't hold onto him and run fast enough at the same time. He was buried by the rubbish.” I tried to console him, I tried to tell a colleague what happened, and then I realised I was falling behind, spending too much time with this non-critical patient. So, I left the patient crying. I moved on. Just work, I told myself. Just work. Over the next 85 hours, I went home for a total of 10 hours and slept for 3. I heard countless stories from distressed patients—none of which I will ever forget. The most memorable occurred on Sept 12 when a port authority officer made contact on his cell phone and was rescued from the debris. He had severe crush injuries to his legs, and shortly after his emergency surgery I became the physician responsible for monitoring him overnight and making sure he did not die. I checked on him every 30 minutes, adjusted, monitored, and changed things I had only moments before learned how to do. I continued to care for him over the remaining few days I was on the trauma service. The surgeons had performed what I believed to be a miracle. My contribution was so small. His story of rescue was in the papers, his eventual recovery and ability to walk out of the SICU months later made news and even brought the city's Mayor to the hospital. The fear I felt every time I checked on him was only something I knew, and something I never shared with a colleague or with the patient. As we worked, New York University Medical Center received one bomb threat after another. Few of the physicians or staff left the hospital. I sent home every medical student, told them that they were not essential staff and should be with their families. I knew that if any of those bomb threats were real, and if any of those students were injured, I would not be able to live with myself if I survived. I remember the patients, the students, and the hours I worked. In the moments and in the days that followed, I remember only one other doctor asking me how I was doing. On Sept 13, one of the directors in the emergency department asked me “Are you holding up?”. Shocked that it took more than 48 hours for someone to ask me how I was feeling, I said I was holding up. That was the problem. I was well trained to just “do my job”. I didn't have time to think about what I was experiencing. If anything, I was more upset than I was worried, tired, or scared. I was upset about the way dozens of doctors, from various specialties, had reacted to what was going on. I was also amazed that all I heard on the television and radio stations was that the hospitals were empty; the doctors didn't have any patients. Why didn't anyone know what was going on? That I had 40 patients—nothing compared to 5000 victims, but three times as many trauma patients than I had ever taken care of before. Why didn't anyone know that I was one of only three interns on the trauma service in New York City at New York University Medical Center. Most striking, however, was how little my colleagues talked about what was going on, or about how they felt. We were all so good at just working, without question and, sometimes, without feeling. During this event, I experienced what may be the ultimate dilemma in the practice of medicine. We are asked to take care of patients without regard for their moral character, financial status, political beliefs, or personal values. We are asked to work countless hours during emergencies. We are also asked to be kind, sympathetic, and empathetic to our patients. How can we be both impartial and empathetic? How can we care if we are so busy with our “work”? Sept 11, 2001 (9/11) was an extreme example of an emergency. It is not the perfect parallel to the everyday struggles of physicians, but it taught me many lessons early on in my career. Nearly 10 years later, practising as a supervising physician at a medical school in a state geographically removed from the intensity of these events, I am aware that one cannot truly be both impartial and concerned. We are capable of working long and often stressful hours. We are sometimes even able to walk that fine line between providing care, and doing so without question. Although the events of 9/11 may be a distant or purposefully suppressed memory to many, I always remember to ask my students and residents how they are doing or how they are holding up when they are working long hours or breaking bad news to a patient. It is funny how shocked they seem. Almost as if they expect, as I did back in 2001, to be rewarded for their speed, efficiency, and ability to work without question. Just work? Perhaps I did not need 85 hours on the trauma service during 9/11 to realise that the structure under which doctors provide care often renders us limited in our ability to provide care for the patient as a whole. How can we properly care for our patients if we sometimes forget to even think about what we are feeling? How can we feel, if during the most important and stressful of times the “best” approach may be to not feel anything at all? Just work.