Psychiatry & Psychotherapy Podcast - Meaning and Decision Making in Times of Crisis

Episode Date: April 22, 2020

On this week's episode of the Psychiatry and Psychotherapy Podcast, I interview Dr. Daved Van-Stralen. During this season of COVID-19, Van-Stralen is focusing on the unique stresses on the healthcare system. How can the healthcare system improve the way that things are currently being done? How can people handle stress and the stress of seeing multiple deaths, exposure to the disease, and increased hours? By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. Welcome back to the podcast. I am here with Dr. David Vend Strelin. He is an expert in health care leadership. He is someone who is a pediatric ICU doctor. So he's kind of at the forefront of the issues that we're currently facing. We've been having conversations for several months. And I thought now would be a good time to bring him on to really take him. talk about in this season of COVID-19, the unique stresses on the health care system, how we might rise above and handle the stresses, the unique stresses that are on. So this is kind of an episode

for the health care worker in my mind. It's for the person in the trenches, for the person who might be seeing people die frequently. And so let's just jump into it. How do you, think that the health care system could improve the way that things are currently being done, especially in this season. Like, how do people handle stress and the stress have seen multiple people die over and over again? Yeah, I'm going to start with stress. Because when my working with people over the years, that's the one, the singular thing that interferes with operations and with performance and leads to people leaving the field,

prematurely. And looking at stress as a demand on an overall demand on us, I do sort out between what's the demand on us and what's an expectation. In normal times, we can focus on expectations because sometimes that's the most important. But in a critical incident when someone's dying, when there's limited resources, austere environment and threatening, we have to sort out what's an expectation, what's a demand, and then forget the expectations. We should be doing that, actually, my recommendation, in normal times, distinguish between the two.

And that way, in an emergency, it's more identifiable what we should drop. What's an expectation we should drop? But we don't have that now, so we're going to jump right into it is number one thing is you don't want to die. So how are you going to die? Focus on that. You're going to get a contaminant from a viral particle. You don't know where it is, where it's from.

So protecting your skin, protecting your clothing is number one. The number two is how's the patient going to die? And we're going to look at oxygen delivery, getting oxygen to the cells. Now you're responsible to some degree for getting oxygen to the cells, but you're not responsible for consuming it. That's the patient. And sometimes that can't happen. But your job now is, and the demand I can put on you is get oxygen to the tissues. The next part of that is how do we know what we're doing?

How do we talk to each other? And I would say that's information. And my experience is people, especially in the health care, they want to help. So when you give information as a health care worker, a lot of times you're trying to figure out how can I interpret it, give meaning to it, how can I help show it's important. What you don't realize is that it's the onus now comes on to you that I do it right. so if it doesn't come across, you take responsibility.

And number two, the person receiving the information may have a different idea of what's going on and what's necessary. And that begins to cloud it. Remember talking to a Vietnam vet in the first round, 63, 64, he was there. And he told me that sometimes they'd be sitting down on a log, on a patrol, and the guy next to him on either side doesn't have any information he needs. But the guy on the other side of him does. And through nonverbal communication and just the two, talking they do. He's able to obtain information from somebody, one or two people down,

who don't know that they have this information as necessary, but he needed it. And that's important. So by staying objective, we can give information that's usable. And that's critical. So those are the main things, is what's the demand? We have to jettison all the expectations. And how do I give information that is objective and articulate? It means it comes together as a story. It means it comes together as a or a scene, a little piece, and it's succinct and that it's just enough to get the information across. Okay, so let's just kind of make this a little bit more concrete. So when you say get rid of expectations,

what might be some of the expectations in this particular situation and how might they be letting go of those, or why is that necessary to let go of those? The greatest expectation is that we can relieve suffering and we can prevent death. And that starts to change the way we think and how we solve problems and process information. When I was in the fire department,

a rescue ambulance, we some heard the jokes about, well, we saved the basement or we saved the chimney, it didn't burn down. And it seemed trite and cute at the time, but as I got older, I realized what they're saying is that had we not been there,

the damage would have been far more. And I noticed that as being the first person on scene on thousands of rescue calls where you walk into a house, you walk into a, up to a car or somebody who's trapped or hurt, and you realize that there was nothing going on before you got there. So anything you did helped. And that became my view of an emergency. My presence, sometimes just my presence alone was enough to help. Any action I took help. And that became my standard for what I did. But when I got into medicine, there was more pressure on people.

to relieve all the suffering, to relieve the death, and sent people back to the condition they were in before the incident. And the reason relieving suffering is critical to me is because I remember one time we had a guy trapped in a car, and his femur was broken and it was a 90-degree angle, front seat, and the sports car was pushed forward. Now, we didn't have the jaws of life like on television. We had to use a circular saw to cut the doors and then to move it, we had to let it wind down, otherwise a spark might hit the gasoline, which is out there. We have a hose line laid in case of that. So I asked a physician once in the emergency department from some assistance and how to straighten the leg. And she said, why do you want to do that? And I said, well, to make it

easier. And she cut me off and said, easier on you, not the patient. She says, you always splint it as it lies. But in that situation, there was absolutely no way we can get him out of the car, short of cutting the doors off and the steering wheel off and then with a device pull the a dashboard away from him. But had we been able to know how to straighten that leg in the small confines underneath the dash, we could have moved him out much more smoothly. It would have hurt at the point.

But the other one, it was like 20 minutes or more to get him out. So sometimes in helping people, you do cause discomfort and you do cause pain. But the overarching point is, can I rescue this person out with somebody and they're in a safer place, more controlled environment? So that's what I look at,

expectations is this something that somebody else wants, somebody else is placed on me, or they've tried to frame it as a demand so that their life was a little easier to solve problems and putting it on me? Wow, yeah, that makes a lot of sense. So there's these expectations. Sometimes we say it's like the shoulds, but it's, it's, they're, they're not helpful. They're not helpful to actually accomplish the mission, to accomplish the goal. And so we have to kind of take away some of those. It reminds me a little bit of my time in Haiti where it would have been nice to try to save someone's leg or arm after, you know, 70 people hit the hospital one time

when I was there. But instead, we just had to do some amputations so that we could get to the other ones. So sometimes you have to make decisions that are really fast-paced. And it doesn't meet the expectations of, you know, giving everyone first world care that we're used to, right? So I imagine some people who are listening to this are going like, I don't feel like we're giving first world care because there's just so much coming in

that we can't handle the load or the deaths. Is that kind of what you're talking about? Well, that is. In fact, I would sometimes do the ICU. I would ask people what we'd do if we weren't there. One, two days before Christmas, we have a 25-bed ICU. And RSV is a winter illness that makes children.

Specifically, RSV causes them. They go apic suddenly. They suddenly stop breathing and they might breathe again. And we had 24 kids on ventilators with RSV and went bed open. And two days before Christmas, people were concerned. They wanted to get their child back to the family for Christmas because they wanted them to be together. They wanted to give good news. And I'd gone all 24 kids, and I was out the 25th, which just came off the ventilator.

And all 24 kids, the concern from... staff and the residence was how do we get them off the ventilator so they can go home by Christmas. And so I got the 24th. We'd only been in ICU for two years and I said, well, where were these kids two years ago? And they looked at me funny and I said, two years ago, where were these kids have been? Because there was no P's ICU at that time. And they thought, and I says, now I used to work at Chalk, which is the next hospital, the next county over. And we didn't have this many kids coming in. So where were these kids have gone? And think about what RSV does. Well, they suddenly stop breathing, and they can stop breathing in the parents' hands.

And the nurse could be step out of the room to get something, and they stopped breathing. And I says they would have died. So these 25 kids actually, when we extubated, those 25 kids, two years ago had been dead. And so I wanted to reframe it to what is the demand. The demand was to take 25 kids who would have died two years ago and give them back to the family as a normal child. But the expectations of, we wanted to give them out by the time of the holiday, began to overwhelm their decision-making and their thinking.

And so you could say is that first world to third world? But even in the first world, you have resources and you have attributes. And sometimes we don't have the resources. Sometimes you don't have a physician or surgeon available. And so if that has become your demand to have a surgeon or a certain nurse or certain person available, that actually interferes with your ability to make effective decision. It becomes a very strong distractor to the point that your performance is impaired and the operation starts to suffer.

What you mentioned there about, you know, what if this place didn't exist? I often think about that and think about how much meaning that creates. Because if people don't have that mindset of like, what if the hospital didn't exist? Well, people, more people would die, right? Right? So people will die. Everyone dies. People usually will die in the hospital because that's where they're taken right before death. And so there's something that is going to happen, going to take place. How can we make it a little bit better? I look at the meaning of this. And whenever we would have three or four children die in a week, it just profuse the unit. You could feel it. And so I would start talking to people. people in small groups. It would perfuse the unit.

You'd feel it. You would feel the time. You would feel the time. The talking was softer. There was less talking. There was more vacant stairs. People would kind of be flooded with emotion and they would sit there and just motionless

because of this flooding. Flooded, they would be frozen. Frozen in the air. Too much emotion and they couldn't process it. Did I help? Did I hurt what happened to the family? What did I do? Did I miss something?

All the different things of the successes, the failures, the what I could have done or should have done, the events kind of come in at once, and because you can't process it because you haven't been given the tools to process this, it comes in and kind of perseverates, and we have one perseverating thought is about enough.

But try adding another, which triggers a third, and then the situation is a fourth, and someone walks by, that's a fifth. And pretty soon you have all these perseverating thoughts cycling on each other, and it shuts down your ability to really respond and sometimes even think. Yeah, so it's like,

we're talking about we started talking about stress. It's like the stress goes from a good amount of stress that can lead to, you know, through recovery and you can adapt to it's like an overwhelming stress. There's three or four deaths on the unit in a short amount of time. And, you know, how our brains are wired are to think about the negative events,

think about how we can prevent the negative events more in the future. And in an ICU setting, you have a setting in which more people who are severely ill are going to come. If there was no ICU, they would just die. If there were no vents, they would die. And so you have a unit, and you are managing the unit as the doctor,

or you are overseeing the unit, you know, kind of like providing some leadership. And so in that moment, I love how you just kind of slowed everyone down and said, hey, where would we be? Where would we be if this place didn't exist? and these people would have died. More people would die. So we're here to sometimes give meaning to the staff that keeps them going, right?

How did you help them get unfrozen? Or how did you help them keep moving, keep working, keep going? One thing I do is on the meaning part is that we shift our frame of meaning. And I point out to them, I says, if I had a room with 10 people, people in there and eight would die. When you eight would die, but if you went in there, only four would die. Would you go in there? And they said, well, of course I would. I said, I guarantee you that after a few days, you would start thinking you should have saved those four. You would stop looking at the four that lived and start focusing on the four that died, and they would have died anyway. And so we want to sort

out, did we do anything for the family? The first thing we do for the family is, and the child, of the person is our presence. And our presence represents all humanity. We have to remember that. You're not a nurse or a respiratory therapist. I worked with one who's even the custodian. And during an emergency, he would rush in there and start moving everything out because he was there.

That was his group. That was his team. And they go in there because they make a difference. But anybody watching sees that. When I first came to the PISA ICU, they didn't like family being in during the resuscitation or really afterwards. They wanted to clean the room up.

And I says, yeah, but if the family sees the room as a mess, they know everything you did for the family, for the child. And that's a hard thing to get across to the nurses because they, from professionalism, they wanted to show a nice room that they were professionally done and prepared for the family so they could be comfortable. I just know, the more of the mess,

the more just jungle that is, the more the family sees you did something. And eventually I'll bring the whole family in, which, of course, in the fire department is rescued. There'd be two of us, no police, no firemen, and we're resuscitating. in grandpa's bedroom, you could hardly tell everybody to leave. This is their house. So I always became accustomed to over thousands of calls to treat with family around. And then as they did that,

they started to see that the family did appreciate that, just their presence. So that's number one. Number two, I want to sort out between response and non-response. Again, you're responsible for delivering oxygen in the tissue as the best you can with what tools you have. You're not responsible for consuming it. And so I sort out to the staff what you're responsible for. And I want to dissociate that idea that they're responsible for the cure, for getting better for this. They're not responsible for the death. And with one resident, I said, you know, they didn't know when to call me. And a lot of doctors' attendings would want to have all this information, the labs and the x-rays. And I said, no, you don't have to have anything to call me.

You can just call me if the patient's not responding. If they're not responding like you expected. And one night, the resident did that. She called me up and she says, Dr. Van Strelin, the non-responders, not responding. And that was enough to get her talking and thinking. And I could ask some questions. And she gave me information that was objective, no interpretation. And we pieced together what to do and we can get control over the situation. And I came down to the hospital to help out then. So I want them to understand. They're not responding. It's not your responsibility, but you need to identify that. And so again, I sort out now, our presence helps. And then if the patient doesn't respond, that's not us. We can find different ways, but the not response is not our issue.

And then what can we save? And we give that person every chance. So families would ask, you know, what percent chances you have of living or dying. And I said, I don't give percent. The nurses would want it. The residents would want it. And I said, look, if you have a 20 percent chance of survival, my job as the attending physician is to make that into 30 percent, not to focus on the others and not to say, okay, we're done at 20. And then if it's 30, I go to 40. And so I do everything. And the fire department said that.

There's maybe a thousand things you can do. You can't do them all, but you do what you can. You do as many as you can. And that's what we do in these emergencies. And if we have constraints, like there's not enough people to go around, not enough equipment, not enough drug, and I've been in those situations, you still give the best that you have to offer.

And it's presented to me once as a new paramedic student, and actually new paramedic. It was in the field. And we got on scene, and it was a single car collision. Afternoon in August, we hot and we took the guy out, and he was immediately onto the asphalt

in the middle of the street. He was breathing and he was fibrillating. And so we tried some treatments that were standard, and we called the hospital, and the physician wanted to keep giving sodium bicarbonate to correct the pH. My rookie did only want to do what the doctor said, and then gradually the patient faded away and died.

So I called this physician, up, a emergency physician who's actually quite famous now. At the time, he was just one of the guys we worked with. And he said, well, he says, you know, you reached out for the man. You reached out for him and held your hand out. He wasn't strong enough to reach your hand. It's not your fault because you had your hand out. Now, no one else put their hand out.

Again, that's not you. You put your hand out. You were the only one, and he couldn't reach it. So you did what you could do. And I tell that story to people because I wanted to understand that the people around them for various reasons may not have their handout. They may have a triggered reaction because of something. They may have a stress and they can't think.

Who knows why they can't reach their hand out? But you can reach your handout, and that's what we're doing here, reaching our handout so that people know that we're there with them. And those around, maybe reach their hand out when they see us do it. Maybe our calm demeanor and our reaching out to help is enough to get somebody back on track. And I've seen that plenty of times.

One nurse couldn't, it was resuscitation, for whatever reason she couldn't participate, but I needed help. So I asked her to mix the dopamine drip up. And so she started mixing it up mechanically because I knew that dopamine in action and stuff it brings you out of a stress response. So she mixed it up and brought it into me

and she says, what do you want me to run this at? And I said, well, set it down and do this, please. And I gave her some tasks. And pretty soon she was right in the middle of the resuscitation, dopamine never got hung, but she was actively participating and talking and thinking and giving me information and listening into it.

So sometimes as you reach your hand out, you might be able to kind of with your other hand flag some people over, and they can help. I want to slow this down because I want people to catch what you just said. You had her do a task outside the room, a simple task that got her back into her mind, into her thinking mind, not into a frozen state.

If you're a fan of this podcast, you may have listened to the episode I did on the polyvagal theory, kind of that that shut down place so we go into the fight and flight and if the fight and flight is for whatever reason not able to accomplish its goal if there's intense fear if there's a near death situation we may go into kind of a more of a shutdown state and you may get kind of stuck in that state and one of the things that I heard from you is you have people do simple tasks that they know how to do well and and for that example what that

person, you had her go get the dopamine drip ready. And then she came back and you had her do other things and it snapped her out of that frozen state. So you identified the frozen state and then you kind of naturally figured out a way through your training and through observation on how to get people out of that state and keep them working towards the goal. Right. I always want somebody doing something physical when they do that. And you'll see that too on the opposite side. I'd read about that with the music industry about the director's knob on a console for recording industry. And it was a nod that wasn't connected to anything. And then only the producer could turn that knob.

And the producer could turn the knob to fine tune the sound, but it wasn't connected to anything. Well, the type of ventilators we had in the ICU back in the 90s had all the dials were on the front open, easily accessible. So there's a plastic shield that came down so that nobody could bump them and turn them by mistake. There was one hole above a knob that went. into different settings. And if you turned it, it would read the minute ventilation, how many millimeters of oxygen

or air would flow per minute, tidal volume, how much puff there would be into the chest, inspiratory time, how fast the air went into the chest. And you turn the knob and you have all these different numbers show up, the positive, the highest pressure, the lowest pressure. And I told people if you watched it,

and I don't want to say if there's any particular specialty, but there were some that were, they would walk over and turn the knob and see the numbers, they would look at the chest and study the chest, and they would turn the knob again, see the number, and they look back at the chest and study the chest. And they would do this several times so they found the number they wanted and they would relax and then we could talk to them. And they had no idea, and I never told them that that knob was simply the display of the different types of measurements. It had nothing to do with the delivery

of air through the ventilator. So they found comfort in turning the knob. Doing something physical. Doing something physical. Okay. Also, another thing you mentioned prior was that just doing things that you know how to do well, check the pulses, check the heart rate, count the respirations, you know, check the monitor, look at the monitor,

things that you know how to read well, get back to what you know. And then I think it's worth reiterating what you were talking about, how describe what you actually see to your other team members and try not to put on your own meanings onto that description. And I try to teach my residents that like tell me what they're actually doing on the unit. Like they're, you know, can you describe their actual behaviors and not jump to the word that we sometimes used to describe that behavior? Because the actual description of the behavior gives us more information. And so you teach here the people that work under you to describe accurately what is going on. Right. And came up with working with some guys out

of the Special Operations Forces. And we were talking because they would encounter physicians at these conferences or experts outside their unit, not realizing how smart these guys were. And we found that the farther you are in distance from the setting, the further you are in time from it, you tend to be more abstract. And that fits in with our cognitive abilities. That fits in with the sciences, our concepts, or abstract. And when we talk about abstract concepts,

sometimes it's hard to get across. So we make them into metaphors and analogies and cliches. And that makes sense because that's how we teach. We all do it that way. On the other hand, working with these guys, and I've climbed, done a lot of mountaineering, including the Himalayas and winter, summer. And when you're in the terrain, you want accurate descriptions. Yes, it's nice enough the water's good, but really more important is, is the water there, where is it?

And, you know, the campsites. So the mountain, the la la la la la la la part, because I do a lot without trails on my climbing and my hiking. And so when you talk about terrain, it's all descriptions. So we tend to be accurate. Accurate is that we could be missing the mark, but with accuracy, I can keep with feedback, I can keep correcting it, and I can hit the bullseye.

If I'm precise with my proper word, it may be wrong, and I'm using this word wrong, but I am precise because I'm using it over and over. And that's like having a real tight pattern on your target, but it's at the outside of the target, and you'll always miss. Hit the same spot every time precisely, but you'll always miss. So when I get into the abstract ideas, and concepts, I expect metaphor analogies and cliches.

When I'm talking about an actual thing in front of me, I want it physical. And what I can use this now in reverse, when somebody starts talking in metaphor and analogy, when they start using cliches, now I know that they're under stress or they don't know what's happening, but they're afraid to say I don't know. And that's an important person to identify in that because depending on their rank and their position and their experience, we have to work with them differently. but they are a difficult group that can be a distractor to an emergency. What I appreciate about what you said there, Dr. Van Strelin, was this is another technique on reducing stress as well.

It's to move into the description of what you see, not the clinic, cliches, metaphors. So give me an example of like a patient that may. may be not doing so well, where the description is what gives it away or is helpful, whereas maybe not the pulse ox. Yeah, that would be a good one because I teach the staff described this way, but also as action response, it's loop decision making, what I do and what I saw. And we had one of the residents in a nursing home, and they don't have a lot of respect for what they do and their ability.

a new transfer of child came in who was agitated on the ventilator settings and out of synchrony with it. The oxygen saturations were low. And so she called the physician covering, the expert in a long-term ventilation and described the child, not so much the pulse oxymetry because it would kind of go up and down. It was unreliable. But she described the out of synchrony with the ventilator. So she'd be breathing, the retractions.

So she did it that way. The altered awareness, she looked at the high heart rate, high respiratory rate, there was some sweating on the skin, diaphresis, there was retractions. On the lower side, sometimes which is softer lung, so it's not so bad, but then also sometimes going up the chest, which means that there's more obstruction going on. And so she described that to the physician, and then she said, when I hand ventilate, this is what happens. and she described the heart rate coming down and the retractions going away and the child not moving, not struggling, and actually opening the eyes.

And so that was one where you would think you can get the description, but the physician intent on having this particular setting, he told her, he said, well, that does work. And she says, yes, and I work with my staff, you never interpret it. She says, it may have worked then, but it's not working now. And he insisted she tried, and she says,

but when I do that, this is what happened. So she said, here's what I see when I do what you say. And he perseverated. So she went and found another physician. And again, calmly, she was actually in tears because of what happens to the child. And the other physician came in. And again, using those phrases, was able to have the ventilator settings change. But she, you know, had the ventilator adjusted to calm the child down and make the child to actually smile.

But to do that, she stuck strictly with. the information of what, here's what I see objectively. She put it together in an articulate way. So I thought about that, and I said, sometimes that's what we want in these situations. We don't want the whole story. We want to have the articulation being, here's where I was, here's where I want to be or I think I could be,

and here's what I want to do in the middle. And in that little story arc, when they all come together, if the nurse, the registry therapist, the social worker, the resident, the physician, the attending, the different specialists and consultants, And so if they all take their little scenes and put them together, you have an incredibly powerful scene, overarching scene, a story that can be now interpreted by numerous people.

And that's what I mean is how do we use this information I described? Well, you want to identify the situation. And that's what she did, the respiratory therapy care practitioner. She identified that there was a struggle. She didn't interpret initially that it's this acute risk failure. She just identified it. And she interpreted it that it needed to be taken care of. and she took care of it, and then she had to translate it,

and so the way she translated to the consulting physician didn't work. So she found a pediatrician in the facility, and she translated to him in a different way. And so by translating it based on who the person is and the information that is meaningful for them, that's selling it for them, she was able to actually, it's distressed, but not the distress that did not interfere with her performance,

didn't interfere with the operation, and it didn't fear with the child care. Okay, so I try to get my head around that story. And basically, through observing what was going on and then observing things changed with hand ventilation, she was able to gather some information. And portrayal of that information helped her get the needed settings from the physician. the thing that I find interesting that we've talked about that kind of this spins off of is how ventilator settings can change someone's cognitive function,

like their total brain function, their sensorium. So we know that, you know, severe sensorium issues we call delirium. Hyperactive delirium is the most noticeable one where the patients are pulling out their lines, trying to pull out their tube, trying to, you know, maybe respond. to some hallucinations, focus comes and goes, so they may be very sedated one moment, very agitated the next. There's another type of delirium called hypoactive delirium

in which the patient is sedated, not responding, kind of confused and looks rather depressed. We've talked about how breathing settings, ventilator settings, can change these states. Tell me briefly what you found in regards to this and how you help kids get to a place of laughing and joking while being on the vent. Yeah, initially it came early in the early 90s

doing the home vent program and also winning people off the ventilator of the kids. I learned how to hand ventilate to calm them down and that was the real deciding factor in my approach was a young girl with a C1 transaction so she was no sensation below the top of the neck. And she let us know through talking that she felt suffocated, but her blood gases were fine.

So we hand ventilated her, found a setting that made her feel comfortable, set the ventilator for that, and then took a blood gas, and the blood gas was the same. One, she felt comfortable, and the other one, she didn't. Since then, I found the first use of curare, which is in a site for the people who are psychological-oriented. That was the proof that all thinking occurred inside the brain centrally, and not peripherally.

That was part of the study. The other study was that he had the same thing, same problem. Change the ventilator pattern to a larger tidal volume, faster inspiratory rate, made him feel comfortable, even though the blood gas was the same. Larger tidal volume, meaning bigger breath. Bigger breath, deeper breath. And quicker, inspiratory. So you're getting the errand faster, longer expratory. Well, the expatriatory's going on its own. People forget that. The lung collapses on itself. So we don't have to worry about how it comes out. It's just the, and anybody can do this.

I have my staff did that. Take a big breath fast, and it just makes them feel good. I don't even tell them what I'm going to do. I just take a big, deep breath, and they'll say, yeah, and they do it. And when I was on the fire department, an ambulance back with guys from World War II,

Korean, Vietnam War, they'd watch you. And I didn't understand it until now, but, and they would tell you, take a breath. And you did, and okay, you can how you think. And I never made that connection, but these guys knew going back into World War II that when a young guy, someone's concentrating to me,

much. You can tell because they're breathing gets shallow and then they don't think as well. And so you take a big breath, you kind of break out of that and now you can think clearly. And so it was the kind of thing that I was taught in the 70s, or not taught, told to do. And now I finally understand there's some science behind it. So in working with some of these kids, we would have them come over and being in a nursing home, you couldn't sedate or paralyzed patients. So we kind of had to do what you could. And that's one thing in the COVID period now, that things that we're We thought we had to have done, we have to have, we've got to do. Now we're finding out that when I have my choice between two or three items, some of those

may not be important. Some of those may not be necessary and that we can get by without it. And that's what I learned with the nursing home. So a child will come over and be starting to struggle to breathe. And, well, we have to hand ventilate them because they're doing so horribly. We can't sedate them. So the staff would learn how to hand ventilate somebody who's breathing and take over, which is now a technique used by one of the elite special operas.

operations units. I taught it to them three years ago and it's now standard. And it's actually in their training program for their medics. So they had hand ventilate and I walked in once on one of these. And just as I walked in, they had everybody running in to help resuscitate this child. And I saw the respiratory care practitioner reach over and start hand ventilating and she immediately smiled.

But that was odd and she said, oh yeah, we see this. So I started paying closer attention and found out that we could do this. Now the other side was when we were hand ventilating, putting these kids on ventilators, because they would gradually fade away to breathing. So we'd put them on the vent. And so I told the staff to keep the rates down below 20 because we don't want any problems with prolonged expatory phase

and the breaths run into each other. They stack up and they breathe. That doesn't work. It's inefficient and they die. So I kept getting on them to slow the rate down. And then finally one gal, Peggy just got really angry with me. He says, you know, you keep telling us to hand ventilate, you know, set the ventilator settings that are calm.

And now you're telling us to turn it down low. is they don't stay calm that way. And then I realized that if I put somebody on a ventilator and then I show them a funny movie or tell them a funny joke, I wouldn't tell a funny joke, but somebody might that would work. They can't laugh because if they laugh

that out of synchrony of the ventilator and if they can't cry, and so they turn and they shut their emotions off. And we found that as we had higher rates, which the ICU physicians and the standard public stuff out there says is unsafe, wrong, or gives you bad blood gas,

I found the kids now were laughing and playing. They did. And we had another child who had a brain injury from a motor vehicle collision and transferred to us for being vegetative. And after two months, one of my risk of care practitioners saw some trouble breathing on the kid. So she walked over and hand-vinated him, and he woke up and said, thank you. And he had been given to us as being vegetative. So we have all these stories of these kids who have been that way. Now, I did have an educator. The work's not supported because I guess it's too odd for some people. The school district wants to pursue it, but medically it's not accepted, it seems. But he would know when I did ventilator

adjustments, he told me later, because he said that the kids woke up more. And a number of these kids, we had 15 of them who were marked as vegetative, and he put this device that picks up brain waves. And when you put them on the ventilator and adjust the ventilator settings and the brain waves can be picked up or the eye movements can be picked up, they can communicate through the computer, we found that probably about seven of those kids who were vegetative were actually able to interact. One girl had gone from the, I think she was sixth grade reading level, up to ninth grade reading level in one year.

But she was vegetated when we got her. Wow. So you said low rate but then high rate at different points. Yeah. So tell me. Yeah, it was, we're going to split into two different components. One of them is to calm the person down. and make them feel better.

And that's when you have a low rate with a large tidal volume. And that fits the idea of the yoga breathing or relaxation breathing. And so that is an interim thing. Anybody can do it right now and feel better. But if I have the ventilator set for that and I have them laugh or they cry or they see their mother and they get excited, now they're going to be breathing faster,

but the ventilator is set for this low rate. for relaxation breathing, but now they want to breathe faster because they're excited, they're laughing on this. And so that's the quandary of trying to explain this to people because there's two parallel issues. One of them is to make them feel relaxed, and the other one is to be available

when they start to become laughing or agitated or crying. As a result of that, we do tend to ventilate the children and they get a respiratory alkalosis, but that's been known since the days of the iron lung, and I have used iron lungs and children in the home vent. clinic in the early 90s, but people who are on these ventilators will over breathe and put themselves into a respiratory alkalosis. And then, of course, the blood gas is wrong and it's euboxia.

All the boxes have to be filled outright. So they get a blood gas and the boxes are wrong. So we have to adjust it. And pretty soon now we're back into that hypoactive delirium and the child won't become agitated, but they won't move, they won't look, they won't look around and they won't interact. or I tolerate the respiratory alkalosis and then they end up playing more. And what's odd about it is, again, these are numbers and we do uboxia. So if you look at the number of hydrogen ions

between 7.2 to 7.3, that's way more hydrogen ions than 7.4 to 7.5. And so to some people who look at just the numbers, it's a big change. And it's not. because we forget that pH is the negative logarithm. And so the lower numbers have bigger changes. And so when the physicians get angry with me over the pH of 7.42,

they don't realize that's a smaller change, 740 to 742, much smaller change than from, say, 720 to 73. Aha, yes, very good. Yeah, so this is a good little side discussion. about, you know, do we as physicians treat people to boxes, do we treat people to their blood gases, or do we treat to what we see, what we intuit, right? And what you're talking about is we may actually be treating people incorrectly if we don't also take into account, you know, what type of state they are in psychologically. You know, are they in that hyper, you know, are they in that hyper,

active delirium, the low sensorium based on how we're kind of ventilating them versus, you know, getting them into a little bit more alkalosis and they're actually laughing and joking and having a good time, I'm able to communicate better. It's like, okay, guys, like let's not like it's so monolithically focused on the boxes, you know? Yeah, the problem we have explaining that sometimes is the quality of life measures, which everybody loves to throw at me. What's the quality of life? don't include smile. And so I'll ask sometimes if they're willing to talk to me, is the little child smiles?

And they say, well, yeah. And they says, but they have all these things like they're on a ventilator. They can't move. They're this, this, and this. And I says, yes, but what would you do if you had a patient in your clinic or in the hospital? They went three months without smiling. What's the mortality rate on that? We're talking about severe depression and not smiling and loss of life.

People in the ICU and emergency department, even now, are going to be to this point, where they can't smile. And that's serious. Well, in our population, you think how much you can tolerate if you can smile, because smile connects people to each other. What's our first social interaction

is the social smile? In my model of leadership from pediatrics development, the first thing that a leader does is develop a relationship with the subordinates. And what's our first thing we do in life is we smile for that relationship? It's clearly important

for communication. And so in these emergencies, I know sometimes the staff would get angry with me for my humor. Actually, being one of the first paramedics, if not the first paramedics, to go to medical school, I learned to keep my mouth check

because I got in trouble a lot. And probably about every month or two, somebody would ask me if I had been a fire department paramedic, and I asked them why. And they said, the way I talk in my humor. So I do know that, but I like the quote somebody years ago

had said that I came across that the world, is a comedy to those who think and a tragedy to those who feel. And in our field of critical care, emergency care in this EMS, we actually get both of those. We have to think and we have to feel. You have to feel because that's your duty.

You have a sense of duty to what you do and you do it automatically because that way you just act. You're just driven to act, which keeps lower the stress. But we also, that's the feeling, but we also have to think because we've got to be thinking while we're doing this

so that we can bring some support help and help solve this problem. Because what we do is we solve problems that the person cannot solve themselves. And so we're bringing our thinking in. We're bringing our feeling in. And so sometimes we look like we're smiling or at the wrong time or thinking at the wrong time. And I know opening the PSEU up being brand new, the staff had a hard time bringing those two together, merging them together into one personality trait. Yeah. You know, I was thinking, thinking about how not this week, but a couple weeks ago when this stress was just first hitting our department and we were moving everything to video calls and I was on call and I was

working hard and I was in the hospital, you know, seeing lots of patients. I was at home and I was jumping on the trampoline and my daughter noticed that I wasn't smiling at all. And both my kids, you know, this is a, what, four-year-old and a six-year-old, okay? And she's like, Daddy, you're not smiling. And they both try to start tickling me because they want to get me into that playful state that I normally am in, you know, on the trampoline. But everything that was going on, I was like in a very sympathetic fight-and-flight state. And we don't really laugh. We don't really smile in that state. We're more like, you know, like boots hit the floor. Let's get moving. Let's survive, you know. And so there is something about humor. There is something about even, you know,

dark humor that and sometimes about just the smile and also what you were saying before, presence, right? Presence. Those things are very powerful in getting us into that state where we can think. Because if we're in more of that fight and flight state, you know, blood is rushing from our brain to our muscles, blood is rushing from our GI tract to our muscles. Like we're basically we weren't trained like evolutionarily to react to large amount of stress with very, very thoughtful action.

And essentially as physicians, we are needing very, very thoughtful action in the midst of stress. Any thoughts on that? Yeah, it is. When I was in the fire department, we worked with just two guys, no cops, no fire,

and the whole city, L.A., It could be a drug area. Gangs are moving north out of, you know, in Los Angeles from Compton. And one thing I was taught was if you're in a situation like that, because we didn't have radios so we could be in where we couldn't get out for help and escape, is take a roll of gauze and give it to the biggest dude unseen. And he now became part of your team. And I thought it was kind of foolish till a few times when it did get a little tense.

and those guys would step in between us and the other people. And, you know, I can't ask somebody to get into a fight for me, but they did it because they're my team. And the smile is that connector. It tells you what's going on. I use it as a gauge if people aren't smiling or can't have a break of humor. Then I know that they're being overwhelmed. When I start hearing jokes and humor about some activity,

I realize it's also a sense of accomplishment. That's another function of humor. It shows a sense of mastery. It's like potty humor occurs after the child learns bowel habits. And dating humor occurs after an adolescent learns how to date, and then they start making jokes about it. So one level of humor is it tells me that they've mastered something, and they're starting to eat the mastery.

And the other one is that it tells me, are they so tense in a survival mode that they can't see that anomaly, the paradox? And that's critical because humor comes from paradox, and what am I looking for? On vulnerability, I'm looking for the paradox. I'm looking for the thing that doesn't belong. And yes, that's a classic model of humor, but it's also exactly how I find my vulnerability.

There's a disruption here. There's a discrepancy. Now I have to look at it. I've got to sort it out. So is that humor or is that life-saving? It's simply how you label it. You know, I've been thinking about, like, attractiveness. And one of the most attractive traits is humor.

And actually, you have to be pretty intelligent to be humorous. because you have to be able to assess what the other person is going to find humorous. And so if you look at a lot of like YouTube and TikTok, there's something about high humor is very, very popular. And it makes someone very popular, right? Especially males are largely famous on social media for humor, at least on TikTok. And so it's like this, it's like, it's like, this high attractiveness feature which also is highly connected with intelligence. And just a side thought.

Well, no, that's important, but there's also the negative side we don't want to forget about because there is the sarcastic, the humor made to hurt or pull somebody else down. And then the humor, the scatological type that when I start hearing that, I know this person is very much under stress because now they've let their guard down and there's stuff as just coming out. And those are two areas that I do watch. for. So humor is not just simply a joke to laugh at. To me, it's equivalent of reading the room and telling it's, let me be the psychiatrist go of the dreams of the royal road to the mind.

To me, humor is. And what they're laughing at, what they're joking about, how the humor come out can give me a, you know, insight into how they function under stress. Yeah, yeah. Can, I personally do not like when humor is dehumanizing. even if it's like to take the edge off of situations, I try to stay clear of that, and especially if any of that pops up in my training and interactions with medical students or residents,

I really just kind of try to shut that down. The dehumanizing, I got to say about the dehumanizing, because I do come across that, sometimes in people sitting around. But my concern when I see or hear the dehumanizing humor is that what you said I agree with, but very concerning to me is somebody

who is now so strong, stressed, they have to dissociate themselves with this individual because in a sense, if it happened to them, it can happen to me. So I have to dehumanize them. I'm going to tell the family screwed up. The family was as bad. The person did this. It was their fault. And when I start seeing that dehumanizing, it can be done to make it socially acceptable, become humors, or it can be that I'm this insightful, wise person who's announcing that this person is no good. But very quickly, that goes to the person who doesn't deserve our medical care. And when I have seen that happen, and I've seen that in very good people, very religious people, spiritual people.

And when I start seeing that, I'm very concerned. The system, the unit is starting to fall apart, and that person is falling apart. Yeah. Yeah. So I want to bring this to a close. So kind of to summarize some of the action points of how to deal with high stress situations, one is to continue to come back to the meaning that if we were not here,

more people would die. So we are here. not with the expectation that we are going to be able to relieve all suffering, but with the onus or with the desire to try to make people's lives a little bit better and to help in any situation that we can help, right? Number two, our presence is powerful to decrease stressful situations. Talked about our physical presence, maybe even doing some of those calm breathing, ourselves, taking deep breaths.

if we ourselves feel very stressed, ground ourselves in actions that we know how to do well, checking monitors, checking breathing, you know, physically coming into the space of describing in our mind the situation so that we can describe it clearly to someone we might get supervision from, right? So then the other part of stress would be to have people that you can talk about cases with if you don't, if you feel stuck, if you don't understand it. Even if you're top of your field, there's other colleagues that you can use this method, describe what's happening. Hey, what do you think of this situation?

This is the description. Yeah, any other big things that are jumping out at you that I'm missing here from practical applications of how do we decrease stress as healthcare workers in the trenches in this season? I say kind of to paraphrase one of your points is the controllability. when I have my staff, if I see the lack of controllability, that sets off the stress, which this sets off the steroid response. They can't remember things. Their memory's gone.

And controllability, and this is actually quite a critical point, I have an objective I need to reach. And I can't reach it for some reason. I want people to decompose it. I want them to decompose it to something they can reach and be controllable. The second critical point is I have. have more than one plan and you can do this with people. Ask what are the five objectives for this patient. The first two are easy to think of. The third and fourth and fifth are critical. So, and people, sometimes get angry with me. I says, okay, what would you do? They give me their

plan. And I says, okay, that doesn't work. And after the third one, they're very angry. The reason I do this is that I want them to have two or three ways to do everything. I want them to have the ability to decompose any objective to smaller objectives. So no matter what happens to them, there's always some control ability. They can always reach a tiny objective no matter how small. And if it doesn't work, they can come up with three, four, or five different things that get them there. And that motion forward starts their brain thinking again. And it's incredible how quickly that works.

Right. So I'm kind of drawn back to some stoic thoughts, actually, where he, in the Marcus Aurelius wrote these kind of notes to himself that later got published as a compilation. he never expected it to be given to anyone but himself. So he'll say to himself over and over again in this text, focus on that which you can actually control. Focus on any of your emotions, your thoughts, your decisions, you know, that which is outside of your control, like, you can't control that. So focus on the things that you can control, right? and I come back to that as well as kind of like, you know,

applying a little bit of historical thought to what you were talking about here. Well, it's been a pleasure. Thank you. And I really liked your last point. And, you know, it's interesting that people get upset sometimes at how training is in medicine, that it's tough.

And there's this pimping sort of, they call it pimping, which basically means we ask difficult questions to medical students, and we find out where their gaps of knowledge are, right? and we're preparing them for stress moments like this. So if you are in the midst of this stress and you heard that, you're probably like, oh, yeah, I get it. Medical school was very tough. I don't think anyone has an easy time through medical school.

And it's tough because in residency is very tough too, you know, 80 hours getting kind of pushed around quite a bit. But that psychological environment creates people. people who are capable of performing at a high level in the midst of these times. So I want to encourage you if you are in the trenches right now, like you were trained for this moment. You were trained for this time to rise above, to stay focused, to help those that you can't help, to continue to come back to that. Like, okay, how can I help this one specific person? How do I get the oxygen to them? How do I read them and maybe go with my intuition? right go with intuition not just the labs not just the blood gases like look at the actual person go

with the intuition because we're pattern forming creatures our senses are powerful and yeah so i just want to leave it there i hope you found this interesting in the show notes i'll put a link to his book which is a very detailed account of of how health systems work and how to improve things Anything else we want to say as we close up? Well, I have to quote Dan Kleinman, who was one of the six of the largest organizations in the federal government for running the biggest disasters we have. And he would make sure the guys had what he called the fun button that they would wear. And if he saw somebody not smiling and getting too tense, he would say, you know, are we having fun yet?

And he would tell him to hit the fun button. If they didn't do it, he would hit it for him and they would smile. He always want to make sure that his men were always able to smile at these disasters. he was encountered. Yeah. And that's kind of coming back to, it's most helpful for us to stay in that sort of grounded, full brain, integrated person that we are, right?

And that's where we're thinking to Claris. That's where we're going to make the best decisions. And, yeah, wow. It's been a pleasure. Thanks for coming on. And we'll leave it there. Thank you.