Episode 080: Meaning and Decision Making in Times of Crisis
On this week’s episode of the Psychiatry and Psychotherapy Podcast, I interview Dr. Daved van Stralen. He is a Pediatric ICU doctor who specializes in HRO and is the author of High Reliability for a Highly Unreliable World: Preparing for Code Blue through Daily Operations in Healthcare. He’s also worked with the military’s Special Operations Forces to educate them on different ways of handling stress and overcoming adversity.
Daved Van-Stralen MD, David Puder, MD
There are no conflicts of interest for this episode.
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?
Demand Versus Expectation—Decision Making In Times Of Crisis
Van Stralen says stress is the singular most important thing that interferes with operations and performance. Overwhelming stress can lead to people leaving the medical field prematurely after years of preparation and education. In this time in particular, we need to figure out the difference between what’s a demand (basic requirement) on us as an individual, and what’s an expectation (added pressure).
In a critical incident (like COVID-19) when someone’s dying, we have to sort out what’s an expectation, what’s a demand, and then forget the expectations. We should be doing that in normal times—distinguishing between the two—but right now in particular, it’s imperative that we are able to do that. For example: right now, healthcare workers everywhere have an overarching belief (expectation) that we should be able to prevent pain and death in our patients. This is nearly impossible in this level of pandemic.
Still, these expectations change the way we think and how we solve problems and process information. When we’re helping a patient, we’re responsible for getting oxygen to their cells, but they’re responsible for consuming it (to an extent). We’re responsible to do all we can to protect ourselves, and still show up for our jobs as healthcare workers. We need to protect our skin, protect our clothing, and communicate clearly with each other.
Anything we do to move the ball forward is helpful
As healthcare workers, it’s also important to remember that if we were not working, many more people would die.
An easy way to delineate between an expectation and a demand is usually that an expectation is nebulous. It is sometimes to appease someone else and it involves the word “should,” like, “I should be able to always take away pain.” Demands are specific, move the ball forward, and provide the best care in the immediate time you have. Sometimes in situations that are fast-paced and high volume, we can’t meet the expectations of giving everyone first-world care that we’re used to giving. But, we can follow the protocol we know, and we can do our best to meet the demands of each life-saving and life-extending action we take.
As an example, in a brand-new children’s ICU unit Dr. van Stralen helped develop, 25 children were on ventilators two days before Christmas. They had RSV (respiratory syncytial virus). The hospital staff felt rushed to get the kids home in time for Christmas, and felt guilty they weren’t able to accomplish that goal. The demand was to take twenty-five kids who would have died two years ago (because there was no children’s ICU in that town two years before) and give them back to the families as a normal child. But, the expectations of “we want to get them out by the time of the holiday” began to overwhelm their decision making and their thinking. Dr. van Stralen reminded his team that none of the children would have survived before the ICU was available, and to simply focus on taking care of the children, holiday or no holiday.
Sometimes the “next best thing” is the only option in a time of crisis
Even in the first world, sometimes healthcare workers don’t have the resources they need. Sometimes we don’t have a physician or surgeon available. If your demand is to have a surgeon or certain nurse available, that actually interferes with your ability to make effective decisions to move the care forward in each case. It becomes a very strong distractor to the point that your performance is impaired and the entire operation starts to suffer if you can’t see or develop levels of options.
When we freeze, we can’t think. Our emotions take over (or shut down) and we can’t process what’s happening. We get bogged down in expectation versus a simple to-do list. We question ourselves—”Did I help or did I hurt? What happened to the family? What did I do? Did I miss something?” With enough of these thoughts, we can shut down our ability to respond and even think.
Remember the positives
A moderate amount of stress normally is followed by a recovery period, and then being able to adapt with new strength. But a bad amount of stress (overwhelming stress, or ongoing stress without time for recovery) can lead to shutdown (numbness, high self doubt, freezing in fear, nausea, dissociation).
Even in normal times, our brains are wired to think about negative events and how to prevent negative events in the future. But in times where we are more shut down, we may be flooded with negative emotions.
In an ICU setting, it’s natural that more people who are severely ill are going to arrive there. It’s easy to focus on the death rate, the losses, the difficult moments. If we zoom out, however, we can see clearly that if there was no ICU, those patients would just die. Or, the other ICUs would be overwhelmed more than they already are. Look around and see how many people you’ve helped. Notice the patients who are breathing more easily. Notice how many people who have been discharged.
If you are leading a unit as the doctor, or you are overseeing the unit and providing some leadership, take some time to stop and slow down and remind your staff where everyone would be without that ICU. Sometimes we are here to organize and push our staff, and sometimes we’re here to give meaning that keeps them going.
By shifting our frame of meaning, we can shift our ability to perform in high-stress environments like the one we are all in now.
How can we function, even when we’re overwhelmed?
The first thing we all offer for the entire sphere of each patient is our presence. Our presence represents all humanity. We have to remember that. Anybody watching you work sees how hard you’re working for their family or loved one. When Dr. van Stralen first started to work at the pediatric ICU, they didn’t like family being in the room during resuscitation, or immediately afterwards. They wanted to clean the room up first. He argued that if the family sees the room as a mess, they will know everything the doctors and nurses did for the family or the child. It showed how hard they worked, that they cared, that they were as intent as they could be on helping the person survive.
We need to disassociate from the idea that healthcare workers are responsible for the cure and for the patients’ recovery, for getting better. We can try to find different ways to change the situation, we can follow different protocols and offer the best care possible. But, the non-response is not our responsibility. We can only do our best to give every person every chance to survive.
Do your best
You can’t do everything, but you do what you can. You do as many things as you can do. And that’s what we do in these types of emergencies. If we have constraints—there are not enough people to go around, not enough equipment, not enough drugs—you still give the best that you have to offer.
Dr. van Stralen says he was working on resuscitating a patient and a nurse on his team froze. She couldn’t move and didn’t know what to do next. He asked her to mix up a dopamine drip for him. She left the room to complete a task she’d done a thousand times before. Once she returned, she asked how he wanted to use it. He told her to put it down and help with something else. He knew that by getting the nurse to switch into her own confidence through performing a task she’d done before, he could help her snap out of shut down mode.
He gave her some other tasks and pretty soon she was right in the middle of the resuscitation. The dopamine never got hung. The nurse was able to actively participate, talk, thank him, give him information, and listen.
Snapping Out Of Shutdown In Stressful Situations
If you’re a healthcare worker in a hot spot like New York, you’re probably overwhelmed right now. When you are overwhelmed, it’s natural to freeze. When you freeze, like the nurse in the previous section did, how can you snap out of emotional shutdown?
Do something physical that you already know how to do well. Check the pulse. Check the heart rate. Count the respirations. Look at the monitor. Get back to what you know.
Another way to sort of “come back to yourself” in times of stress is to be able to give feedback on patients and treatments, communications, that are descriptive. Don’t use cliches and metaphors. So, instead of saying, “A patient isn’t doing well,” give examples, list what you see, be specific.
Notice the total picture of the patient. Does the patient look sick? Are they confused with low sensorium? What’s the mood? We are all people, including patients, and don’t forget that mood and attitude, psychological states, can change outcomes.
If you don’t know what to do in a certain case, talk to a colleague about the patient’s situation. The more you talk about it, particularly describing rather than explaining, the more likely you are to understand what is going on. You’ll snap into yourself and get over any type of freeze. When the other person makes suggestions, even your rebuttals can give you clues as to why you sense something is or is not working.
Dr. van Stralen suggests developing five alternative options for treatment for each patient. The first two are easy to think of, but the third, fourth, and fifth are critical. Each treatment must work. They need to be specific. Having five objectives makes sure each healthcare worker has two or three ways to do everything. We need to have the ability to decompose any objective into smaller objectives. So, no matter what happens to the patient, there’s always some controllability on the healthcare worker’s part. 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 to get them there. And that motion, the motion of knowing a plan before they need it, starts their brain thinking again.
As Marcus Arealius said, focus on that which you can actually control.
You Were Trained For This
Medical school, nursing training, any kind of medical training is not easy. You were pushed around, questioned, run through the ringer. So, I want to encourage you if you are in the trenches right now, you are trained for this moment. You were trained for this time—to rise above, to stay focused, to help those you can help. Continue to come back to that.