You Can Only Do What You Can Do

full steam a head

Triage is all about sorting out the sick from the un-sick prior to the application of limited resources.

It is a vital part of the job we do.

There are times when it feels like bailing water with a teacup on a sinking ship.

A well designed Emergency Department will have enough nurses and doctors to handle the daily expected volumes of bellyaches and runny noses as well as the chest pains and traumas. It will also have a good triage system where a nurse puts eyes on a patient on arrival and determines whether they are sick or not sick.

Yet there are always time when you will get fooled. Patients lie -- often because they don't know the truth. They don't know the important information, or their presentation is unusual, their story is vague. The medical team goes down the wrong path -- prioritizes the labs before the head CT or vice versa.

There will always be times when a department gets overwhelmed and resources just aren't available. Things get missed or miscommunicated, computers go down. Things go wrong.

I've just been through a week of these brutal days: Of restrained psych patients tipping over their gurneys and ambulances coming through the door of our little ED two at a time. Six 12 hour shifts of waves crashing against one doc, two nurses and a tech.

On my last night, I knew I was in for another 12 hours of pounding surf.

When the day shift nurse gives you a hug because they are so glad to see you come on, you know they've had a brutal 12. It took us a while to figure out that the misery to acuity ratio was out of control. Once we sorted the drama from the trauma, we took care of the sick people first and finally got thing restored to baseline chaos.

We spent most of the night, feeling like we were underwater and no amount of swimming was going to bring us to the surface.

I could see it in dayshift's eyes as they were leaving. The next shift finally comes in to clean up the mess and you kick yourself as you go home. It is tempting to blame others, or blame yourself for what went wrong.

Yet, blame doesn't fix anything ... and doesn't make anyone feel better or work better.

When other team members make a mistake how we respond can be the determining factor in helping that person recover and get better. As author Justin Bariso writes:

"leaders are in a unique position to help individuals recover from mistakes. When a leader keeps his or her own failures in mind, it's easier to use words to encourage and build up than to dishearten and tear down. By choosing to focus on the positive, skillfully sharing your own personal experience, or simply reminding the person that everyone has a bad day, you do everything in your power to help that person recover."

Of course we need to review the breakdowns in the system to make it better, to innovate to better allocate resources if possible. When the heat of battle has died away, we need to talk to our team to discuss what could have gone better. We need to learn whether we got it right or got it wrong. That's why experience in emergency medicine is the most precious resource.

However, internalizing our mistakes can take the form of self-abuse, battering our confidence and diminishing our ability to make decisions that have to be made.

It is times like this when I find myself consoling my coworkers with a mantra I've picked up over the years.

"You can only do, what you can do."

As a human being and as a system, resources are finite. We cannot see or know everything, we cannot be everywhere at once. We must triage and prioritize our tasks, triage the demands on our minds and on our souls. We are not superhuman and we cannot bear all the burdens of the world.

Nor should we expect that of ourselves or others.

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Required reading: A Lesson in Leadership

Sharpen Your Ax

http://en.wikipedia.org/wiki/William_Wallace_Denslow

There are always times when we do too much, take on too much and allow the weight of the world to be placed upon our shoulders.

We think we are strong and can power through anything and we suffer in silence, warped in the warm steam of our own stress. Our ego is swollen and fed by our labors. We tell ourselves that no one else knows how hard we are working. No one else has their nose to the grindstone like we do. We are martyrs. We look around and everyone is enjoying the sun, laughing while we slave away.

When I was trying to get into nursing school I took a college algebra class with a friend who was trying to get into dental school. It was summer session, so after a long class, we would go to the tutoring center at the college to grind through hours of homework while the world lolled about in the sun. I wanted to be home with my family and my new-born daughter Grace. I hated math, hated that I was in my late 30's and starting from scratch trying to build a new career to support my family.

I would grind away at the homework, never taking a break or allowing myself a moment of daydreaming. "I have to get this done," was the mantra that a mouthed with each new problem.

Each day my friend and I would start our homework at the same time and each day we would finish within a few minutes of each other, closing our books and walking out together.

Yet my friend would punctuate his homework with frequent stretches and walks around the building to enjoy the sun. One day while walking out I asked how he manged to get the same work done while finding time to sit on the grass while I was working.

His response is one of my favorite parables - one which my friends have often heard me repeat.

Two lumberjacks went into the woods one day, he said. One was young and ambitious, the other was old and wise. The young lumberjack was eager to prove how much stronger and faster he was and so he worked furiously throughout the day, never taking a moment of rest. As the day progressed, he often found the old lumberjack sitting on a stump relaxing while he worked. He felt sure that his dogged efforts would outstrip the old man when the tally was made at the end of the work day. 

Yet when the work was totaled, the old lumberjack had equaled the work of the strong young man. 

How could this be, he asked in frustration. It seemed like every time I looked around you were taking a break. How could you possibly chop as much wood as I did? 

The old man smiled and said: 

"Whenever I took a break, I was sharpening my ax

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