Emergency medicine is a supra normal job where you are exposed to such a volume of stuff. There's anger. There's misery. There's tragedy. And even on a great day, your cortisol and your adrenaline are maxed. Alright, ladies and gentlemen. Welcome back to the podcast. We are here graced by the presence of doctor Rob Orman once again. Rob, thank you for being on the show. Thank you, my friend. Always a treat chat with you. Always treat me back on EBM. I love EBM. You know what EBM reminds me of?
Tell me. A blue chip stock. Oh. Yeah. We just got a bunch of the monthly handouts. They're basically the world's best review articles. I mean, I know that's what you talk about in this podcast. I had not seen them for years. They are amazing. Blue chip stock. Love it. They are pretty incredible. And thank you to all of our authors who might be listening today for continuing to write them. They're amazing. Yeah. And They're great. This voluminous and all encompassing on a topic that's always
relevant to emergency medicine. It's pretty amazing. Both the adult and the peds ones, honestly. Yeah. We just we just got both of them. Yeah. And there's some smart people that write those things. I mean, I get the pleasure of talking about it on the podcast. And then occasionally, we get to have the author on the show, and it just goes to show you how smart they are because I just sit there and You're the the talking head. I am. I'm basking in their intellectual fortitude.
It's just it's amazing. So I asked you on the podcast today to talk about trauma, And I didn't mean the type of trauma that we're used to seeing in the emergency department, or at least that we're aware of seeing in the emergency department when we talk about things like trauma alerts and victims of trauma. We had a recent event here in Tallahassee, Florida where I live, where the Florida State University campus experienced an active shooter incident.
And multiple people were shot, two people died, and the shooter was also injured, all of them taken to the hospital. And there was a lot of discussion around what it would be like to work in the emergency department and experience an active shooter incident and be there in order to accept these patients coming in. And it got me thinking about my couple of decades in practice and all of the traumatic things that I saw. You know, early on in my career, I would go home and
share this stuff with my wife. It was kind of a natural decompression and discussion. But my wife is not a physician, doesn't work in the emergency department. She has experience in medicine and nursing, and so she could lend that ear. But after a while, she's like, I can't really hear this anymore. This is kinda injurious to my mind to hear what it is that you're going through and what you see. And so for the subsequent, you know, fifteen, eighteen years, I just didn't
have a place to share it. It was just this stuff that, you know, we get expert at compartmentalizing, and it went from something I saw at work to something I just stuck in a compartment. And over eighteen years, I think that compartment got gigantic, you know, went from being the size of a small bag to probably the size of a giant house of stuff I just kept stuffing in there and putting away.
And it got me thinking with this recent incident here that we had in town about how much trauma we experience as medical clinicians, especially in the emergency department, and what the best manner is to deal with that, or why should we even deal with that, and what comes as a consequence of not dealing with it. And I couldn't think of anyone else better to have that conversation with than you, doctor Orman. Oh, thank you. I'm thinking about your wife and Yeah. Hearing all this stuff that she
heard. And I just wanna tell you what's popping up in my mind right now. I mean, you and I have I don't even know how many decades stacked on top of each other in the ED and know what this feel like and what this does to our nervous system. And going back to the days when you and I were retraining it, emergency medicine was beyond a burgeoning field. It was really establishing itself, and then it was established. And now it's this leader. It's amazing.
And spent all of these years and decades and, you know, people that were real trailblazers creating this specialty, and how do we do this well? And, Sam, do you ever think about how amazing it is? Just the logistics and the tactics and the strategies and how we operationalize these different aspects of medicine in the emergency department. It really boggles the mind that that's where things
are right now. I mean, it is such an amazing field medically, and it's also this supernormal experience for a human being. And I think about I was at the ENT office the other day, And, oh, then, you know, ENT is walking in. We're gonna talk about surgery and all this kinda that's not super normal. That's a job. Or and I was hanging out with a buddy, this man who's a radiologist. And I sat with him for a couple hours reading field. I don't know. It was
just fun. We're we're already that way. That's not super normal. That's a job. Emergency medicine is a super normal job where you are exposed to such a volume of stuff. And there's anger. There's misery. There's tragedy. And even on a great day, you're just your cortisol and your adrenaline are maxed because the parallel processing that's involved is is past the horn of the bell curve.
And that's the normal aspect of it. And you see these things, and and I'm going back to think about your wife that you are taking this super normal experience which has become normalized for you. And now she is absorbing it with no context. And you are taking all of this stuff that you see, and I I think of it as stuffing it into the seemingly bottomless stuff sack. You know, like, you put a sleeping bag in that stuff sack. Like, oh, wow. It's amazing how well this fits in
here. I got to put two sleeping bags in here. Yeah. Your wife doesn't wanna hear that. That is traumatic to even think about and visualize that stuff. You're talking about the shooting at it was at FSU. Yeah. And, I mean, these shootings have become a regular occurrence. And, yeah, these are big catastrophic events. And, yes, those are traumatic, and those are kind of big t trauma. And, you know, some people are gonna do better with that than others. But let's just define trauma
because we we know trauma. Trauma, injury, fix, better. Or injury, not fix, not better. Mhmm. But the kind of trauma we're talking about today is anything that overwhelms our capacity to cope, and it leaves a lasting mark on the nervous system. We think that, oh, Rama's just in the mind. It's just it's just how we think about things, but that's not the case. That's have you ever heard of this book?
The body keeps a score. Mhmm. So this is written by, I don't know if I'm gonna say this right, Bessel van der Kolk. This is kind of one of the foundational books of trauma and trauma therapy. And the trauma is not just something that happens to you. It's something that gets stored in you. You know? Like, what you're talking about, your storage locker, that dark room in your house. Right. It's it's in your mind. Yes. It's in your nervous system. It's in your physiology.
And I think what you were getting at, Sam, that over years and years and years, that all of these events and all of this stuff changes how you process danger, how you regulate emotion, actually, even what you perceive as a threat, and then how you sleep, how you connect to other people. So how do we adapt in emergency medicine? We push through. We push through. And what you're talking about is suppression, and we suppress. We know we're smart people. Listen to this podcast.
When you suppress something, it doesn't go away. It accumulates, and it very subtly and silently or maybe not so silently rewires us. Yeah. Yeah. And that experience or those experiences are not things that, at least in my emergency department, that we had any kind of tools to handle protocol for debriefing or even post shift recommendations for what to do with. It was just, like, come to work, do your work, and
then go home. And, you know, I heard stories about some emergency departments where they had debriefing protocols after major incidents or major trauma. Yeah. But honestly, I don't even know how they do it. Because in our emergency department, it was like, I literally would get through a resuscitation and then have to walk into another room and deal with the now full waiting room of patients who were waiting because we were in a giant resuscitation. And, you know, what am I gonna tell my next
patient who says my knee hurts? I'm gonna say, well, that's great, sir. But I just spent the last hour trying to resuscitate a three year old child who was with their parent and is now dead. And I just finished my conversation with that parent, so you give me just a little bit of a moment so that I can set my brain around your knee pain and have that discussion. It's like that. I could not say that as a physician, but that's kinda what I was being asked to do. They're like,
okay, great. You talk with the parent, now go see the knee pain. And there were no tools for, you know, how do you handle that? What do you do next? It was just cram it into that sack and shut that compartment and and get to it. You know what? I've gotta tell you what I'm picturing in my mind to say that is that I can picture the trauma bay, room one, the big trauma bay
with all the stuff. I don't know. They're like 17 exam lights in there and, you know, a couple level one infusers, all all this stuff. And, yeah, you spend this time in there. And what I'm picturing is I'm walking out of that room, and I take a left hand turn nine times out of 10 after a long resuscitation. You'll have either the patient or their family member standing outside of their room super pissed off that they're waiting. And it's like, yeah. Oh, wait.
There's such a time compression about that that, wow, I don't have room to breathe. I don't have room to even, you know, process us a little bit. And I said, we think we don't because, oh, I'm beholden to them and their impatience and then, you know, their patient satisfaction, all this stuff. Almost everyone in the ED can wait for you to do what you need to do. The resus bay, critical patient, adjusting event, that can't wait. That is immediate. That is critical. Everything else
can wait. It is hard for us to wrap our heads around that because you just think about opening up a tracking board. And he's like, oh my gosh, all these patients need to be seen. I need to do them all at once, and that kind of this. But you know what? You don't need to be everywhere at once. Those folks can wait for what you need to do. Now maybe that's finished a dictation. Maybe that is to go outside and just, you know, kinda down regulate for a moment.
Maybe I don't know. But Yeah. That was what popped up into my head is the tapping of the foot. And I and I'll tell you this. I was in New Orleans One time. I was with my dad, and we were at the Jazz Fest, and I had a episode of biliary colic. I'd never had that before. It was so amazingly painful. I just the more painful than a broken bone. And the ED doc was busy. I was watching him as a senior resident at the time, and I was watching him running around the ED. I was like, oh my gosh. This
guy is really, really just rocking it. And we had about a four hour workup, and he did all the things. It just takes time in the ED. I can remember my dad walking outside of the room I was in. It was a curtain room and, you know, just getting all huffy and puffy because he was waiting. I was like, oh my god. I am a part of this now? I was so embarrassed. Like, dad, come on in. And he he he couldn't resist. Anyway, let's get back to trauma, shall we? Well, the scenario is exactly that. So, you
know, you can imagine the trauma bay. The patient maybe isn't in there anymore. Yeah. There's 8,000 pieces of used medical equipment strewn all about the floor. There's maybe some blood on the floor, and I'm finally getting a moment to step out of the bay Yeah. After having been in there for an hour and may or may not have already spoken to a family member. And now it's like, okay. Just gotta move on. You know, go see the kid with the fever. Go see the knee pain. Go see the chest pain. Pain,
go see the belly pain. Yeah. Go see whatever it is. And there were times when I would be in there resuscitating with a roomful of nurses, and we end it. And then we're all just standing there staring at each other going, like, now what? Now we just walk out of this door and Yeah. Go back to doing what we were doing before we got in here. It doesn't feel right. It doesn't feel like the next logical thing we're supposed to do. And yet all of us just like, okay. And out we
went. And that just it never set correctly. It never felt like the right thing to do in that scenario. And it leaves an impact. The next day for the rest of the week, every time I walk by that room, I'm thinking about that case. It takes a toll. And what am I supposed to do with that? I wanna pull back a little bit. I do wanna talk about that. You know, what am I supposed to do with this? But I wanna put it in a certain context of what can happen with
trauma. So now we're talking about the trauma that gets stored in us. And so what you're talking about is the habit that we all get into or all well, almost all of us get into. I certainly would include myself in exactly what you're talking about, is thinking that we can power through these experiences. Mhmm. And that locked closet or giant stuff sack will have infinite capacity, and we don't process these things. And that's what you're talking about. We we don't process
it. And this is an important inflection point in these events because what we do with this, how we process this, our relationship to these events can skew things. Now this is not definite, but can skew things either towards integration or disintegration of the event of the trauma. So that may be a term that isn't familiar to the audience. So integration. Can we integrate these experience? And I say that because you and I both know that
it can't unhappen. Once it happened, it happened, and it can't not affect us how it affects us. I mean, this will be hard to say and hard to hear, but I would imagine that you and I remember, I can speak for myself that you remember every child that you have cared for who has had an untoward outcome. I mean, you probably picture them in your head. It's just there. You remember you feel a certain way. You feel grief. You feel sad. Or, you know, you feel feel shame. You feel inadequate. Or
you you feel something. Or you feel triumphant. I don't know. It's just you feel what you feel. Maybe this is a great recess. I did the best I could. Or I just feel sad. You're just gonna feel that way. So integrating these experiences, you can think of that as that means we can metabolize them. It doesn't mean we're okay with what happened, but we have found a way to carry it because we're gonna carry it one way or another without letting it
fracture us. Because we cannot outrun the trauma, but we can integrate these events or we can not integrate these events. So integration means acknowledging what we felt, letting it become part of our story and not something that owns us because we have properly or adequately or at least metabolized it. Disintegration, that is when our thoughts, emotions, our sense of self starts to kinda break instead of working together as a
whole. So this event that happens kinda gets stuck like a bug in the system rather than becoming part of the program. Yeah. And it can be because we've experienced a single event that is too overwhelming to fully process. It's kind of a, you know, like a protective mechanism. So the brain kinda stores it in fragments, and it shows up as you feel like you're not yourself. You can have emotional numbness or sudden outbursts. You can even have flashbacks or memory gaps.
And the difference between these two is the difference between carrying the weight, because it is a weight, with awareness versus dragging it unconsciously until we break. Let me pause on all that before we move on. Yeah. So trying to digest the event and making it a part of who you are in some kind of cohesive way so that you can then continue to
move on. And, you know, maybe acknowledging that, yeah, now I'm changed because of this, but this is who I am now and still functioning as opposed to just suppressing, I think, is the word you were using before. Yeah. Because when you think back on events, you're still gonna think back on the event. It's not that it's not gonna totally disappear. Mhmm. So let's talk about this emotional storage locker for remote with us. So why don't we talk about it? I think
what you're getting at one is habit. It's just, hey. We just go about our business. Mhmm. And there is kind of a culture of, I guess, you should say, toughness or being strong, quote, unquote strong, where you're supposed to bounce back fast, compartmentalize, and move on. Yeah. You know, you deliver the news of death to a family, and then, like, hey, the patient with belly pain is negative CT, and they wanna go home, and they're really upset. Okay. So we don't talk about it.
And what you were trying to do was process this with your wife. You're trying to process by talking about it. Yeah. And so going back to the Resus Bay, yeah, there's so many different ways to do debriefs. And and there is one thing about debriefs is that, you know, if you talk about it too much, you know, it's like, hey. Let's do this debrief and then have a systemic debrief, and then this departmental debrief is gonna okay. That can end up being unhealthy.
But these debriefs in the moment of, let's just take a pause and say, what what's going on? How how did this go for you? What are you feeling? What am I feeling? And that can be done as a group. One way to process we'll talk about in the moment stuff if you wanna get that. But one way to process is to have a set way that you do in fact process. And what happens is is we get to the end of a shift,
and we think, alright. I'm just gonna go home, and maybe I'll watch fifteen hours of Netflix and, you know, veg out on YouTube or have a beer or numb myself this way. Yeah. And that stuff in the brain is just kinda ping pong and ping pong and around, and you're just waiting for the noise to quiet. There's just a lot of unprocessed stuff. Just go away. Go away. Let me be. Let me become a civilian again. You know that it is hard to walk in that house and be a human being.
You know? It's like, hey. Give me some time. I just I need to recalibrate my brain and my physiology. So I don't know if we've talked about this on your pod before. So I I made this free resource called the driveway debrief for this thing. It's on my website. It says roborman.com, r 0 b 0 r m a n Com. This is a driveway debrief. And this is not the only way to do it. This is just how I did it. And so I made a it's like a guided
exercise, seven minute guided exercise. And before you go to the house, in the driveway or a block away, if there's people who are gonna be like, what what are you doing? Take some breaths. Take some deep breaths, and you breathe out for twice as long as you breathe in. And what this does is it activates the parasympathetic nervous system because you are sympathetically activated. You know, you're just on. You're just redlined or just below it.
So take some deep breaths just to settle yourself, and then if you walk through the day, walk through the day, what happened in that day that was great? What were the great moments? What could have gone better? And you just look at it and process and take note of how do I feel? How do I feel about this stuff? Name the feeling. Name the emotion. Oh, sad, angry. What can I learn from this day?
Alright. Now that's kind of a of an intellectual aspect of it, and a lot of the processing is meant to be emotional just to, you know, to pull apart the threads. And then you release the day at the end of the day. There's a visualization to do that. And some and I'm gonna tell you, if you listen to driveway debrief, some people say, oh my gosh. That visualization has changed my life. And other people, that visualization is the weirdest thing I've ever heard. I don't get it. So I'm just gonna
leave it at that. And there is an aspect of catharsis to that. And there's other ways to have catharsis such as through nature, just, you know, a forest bath, go walk in the trees, or debriefing, or journaling or some way to get those thoughts out of your mind and maybe a little bit more structured. And debriefing doesn't have to be formal. What you're talking about is Yeah. You know, in the recess bay. It can be talking to a colleague, can even be just going outside looking at this guy and
settling. Now I will say that when you debrief, you want to be careful that you don't start co ruminating and amping yourself up again, but getting it out there and processing it verbally or in some way, incredibly helpful. I don't even know where we started with that, but I'm gonna throw the law back to you. I think there were oftentimes I was jealous of our nursing colleagues because we would have some kind of event, and then we would
all go back to our desks. And our nurses worked in this little pod section where there were, you know, five or six of them together at the nurse station. And they would stop and talk with their colleagues and and go through what they just felt and what they just saw. And, you know, sometimes they would take a moment and they'll be in there maybe crying or comforting each other or talking about what just occurred.
And in the physician pod, which was just, you know, literally 15 feet away from where the nurses are sitting, it is me and maybe a PA. There's not another physician in there. And I come back and I sit down and I'm just exhausted after what I've just gone through. And I'm looking at the PA who is now looking at me like ragged deer in the headlights, you know, maybe sweaty going,
okay. Are you ready? Because I've been supporting this department for the last hour, and I really need to talk to you about, like, 15 people. And I'm going, okay. I just I just need thirty seconds to just take a deep breath. And then I'm all here. So, yeah, I'm all ears. And I'd look over and I'd go, gosh, you know, like, look at them. Like they're sitting over there debriefing talking they're, you know, collegial covering for each other, the nurses who have been covering for
this one nurse. Aren't like, oh, I'm so glad you're here. You can take your patients back now. They're listening and they're talking. And for us on the PA and physician side, there's no other physician to see patients during this time because of our pod system. The pod is mine. And it was just, you know, okay. Are you done? Are you done playing trauma doctor? Because now it's time to play a medical doctor.
It was just it was a terrible way, and it made me so jealous of what the nurses had just 15 feet away. The system is not set up for support. It's not. It is definitely not. So a couple things came up in what you said there, Sam. And this isn't directly related to what you're talking about with the nurses, but very tangentially, it kinda gets back to the processing. Is there is a difference between reflective solitude. You know, you think about, okay.
I'm just gonna go on a walk by myself out in the woods for a couple hours and think or sit down and journal or even, you know, or whatever it is that I do that is solitude is so nourishing. This reflective solitude versus another situation where you're by yourself, which is isolation. And solitude can be healing. Right? Time to process and reset, but isolation, that's different. You know? It's just kinda I am alone.
And one of the things that can happen in that isolation and that's not exactly what you're talking about with the PA and, you know, the sweating, and I've met managing this apartment. One of the things that happens in any event, anything that happens in our lives is we immediately start creating a narrative, creating a story that we tell ourself about what just happened. And that story can help us flourish.
That story can weigh us down. It can lead to either integration or disintegration of the trauma or the event such as, oh my gosh, this is horrible. I'm not up to the task. That is more likely to lead to disintegrated trauma. Mhmm. Okay. I feel stress. I am up to this. No one else in this hospital could manage this like me. This is the best chance this patient has. Those are stories during the event. And then afterwards, the story you're telling yourself can go unchecked when you are isolated.
I mean, there's so many things about that, you know, when when you're getting back and the PA is just sweating and none of the things that you really want to be doing are happening in that moment. And Mhmm. If it's alright, I'd like to shift gears a little bit, talk about some in the moment things to do. Yeah. And because when we're talking about this trauma and these major events, there's this idea of trauma stewardship. Actually, a
book called trauma stewardship. And that is how do I take care of myself when I'm in a system where trauma is going to happen? And it's things like paying attention to the stuff that nurtures you, like sleep, like food, exercise, relationships, whatever it is you love to do. And how do I frame this? How do I create the narrative? How do I process all of that stuff? Stewardship
of the trauma that's going to occur. And then sometimes the trauma gets so big that at anything that you and I talk about on the show or any of the things that you kinda you you DIY, the trauma can get stuck. It gets stuck. It gets disintegrated. And then then you need some deep work. Things like EMDR or brain spotting or working with a therapist or, you know, somatic work or things that are specifically targeted to manage that disintegrated trauma. And because, you know, it gets wired into
your nervous system. All of that to say, these tools are not a one size fits all. They are not 100%, but they are, how do I approach this in a way that is sensible and workable in my environment to increase the chance of integration versus disintegration of that trauma? Or not even that trauma of just that event. It doesn't even have to register as trauma, but to make it more likely that whatever happens becomes a cohesive part of your narrative rather than something that
is disruptive in your life. How does that land before we get into some tactical stuff? Yeah. No. I like it, and I'm totally tracking with you. So, yes, we all know it can go wrong. And I think if you've been in the emergency department and, you know, worked more than a day, you've probably already felt when it has gone wrong. But there is a better way. And you're saying there are some things in the moment you can do as opposed to waiting until afterwards.
And so tell me about what kinds of things might make it more likely to go well in the moment. Alright. Yes. There's so much processing that can happen afterwards. Just processing that ought happened before having said, okay. Here is how I'm going to be addressing the overwhelming likelihood that these events will occur. Let's talk about that in the moment. And so we have an anti burnout course called Unburnable. It's Mhmm. Primarily for emergency docs, like emergency critical care.
We work on tools to deal with the reality of what is happening in your job as an acute care clinician. Because it's just, you know, the job is what it is. You think, well, shouldn't be that way. Quite. It's that way. But it is. Yeah. Yeah. And this is one of the tools that we teach, and we teach it for a couple of different situations. And this is evidence based, and it is useful in so many different situations.
Whenever you're just kinda getting amped up and you feel like maybe things are getting out of control inside or your physiology is taking over or your inner critic is taking over or some kind of deleterious narrative is starting to push down the accelerator. So this is dropping anchor. Have we talked about dropping anchor No. On the show? Alright. And this is one of many techniques. And I'll tell you, Sam, I'm here all day for you if you wanna talk about different
techniques. You know, there's box breathing. There is reframing. There's so many different things that you can do in the moment, but let's just do two. One of you, this one and another one if that's alright with you. Yeah. Okay. Imagine that you're on a boat out in the water, and all of a sudden, a storm comes up. Your boat is getting tossed around. So you have a couple choices. You can scream at the storm and tell it not to happen. You can ignore it and let the storm
bat your boat around. Storm's still gonna be there. Or you can look for a safe harbor. Steer your boat towards there. Drop anchor until the storm calms down. Storm's still gonna rage. Can I drop anchor and settle? So this technique, it's called dropping anchor. And this was originally developed in acceptance commitment therapy. And it's probably one of the most evidence based tools that applies to emergency medicine. There are many of them, but I don't know. There's, like, 5,000
articles on that. I think it truly 5,000 articles is. So how do you drop and settle in these moments? And it's twofold. It's naming and noting. Let me name what I am feeling right now. What is the somatic sensation that I have? What do I feel in my body? Do I feel heart racing, heart thrumming, a tightness? Is my jaw clenched? Let me name that physical sensation. Name it. Alright. Let me note what I am thinking. What is my emotion? And what that means is changing fact. This is horrible.
I say this is horrible. That is a fact. Two, I notice I have the thought that this is horrible. It's taking a half step back and noticing what your mind is doing. Because, Sarmaid, you know, you and I know a thought's just a thought until that thought takes over and completely controls your emotive state in your physiology. Naming and noting allows a hair of psychological distance from all of this tumult that may be taking over. And along with this, you can just bring yourself back to what
is happening right now. Hope. I'm in the Recess Bay doing CPR. Here I am right now. Rather than going back, going forward, ruminating. Anchor in the moment. And this does two things, and I'll explain these terms. So it grounds you, and that's not grounding in some kind of woo woo way. It grounds you to help regulate the autonomic nervous system, and it prevents dissociation. Mhmm. So grounding, this is intentionally connecting to what is happening in the present.
And what we're doing with dropping anchors, we're doing that through the body, through the senses, anchoring ourselves to what we're feeling. You know, are we overwhelmed? Are we detached? Are we emotionally flooded? Let me just come back to the present. These are things we'd often like to run away from. I don't like that tight feeling in my chest. I want it to go away.
Notice it. Welcome it. Here it is. Now there's much more work to do on this to build this skill, but when we drop anchor, we ground ourselves. We decrease the chance of dissociation. And when we're talking about, you know, trauma, dissociation is where we become mentally and emotionally detached from what's happening in the present moment. Like, we're watching it from the outside. We're emotionally numb. We're in a fog. And that's not a horrible thing. Like, this exists for a
reason. It is probably our brain's way of protecting us when things feel too overwhelming. And Yeah. In the ED, Sam, you and I both know that dissociation can sneak in like a thief in the night. We start zoning out mid shift. We feel robotic, and our brains are a little foggy. So one tool for this is dropping anchor in the moment. I will pause there, and then we can, you know, briefly touch on another tool.
Yeah. I like that. I like that because I think it takes me, like you said, one step away from this whatever this challenging scenario pulls me back, maybe engages that other part of my brain that is, I don't know, more executive in function to give it a name and to give it a kinda to name it and to help frame it in some way that's a little healthier than than where I might go otherwise. I like that. So some folks might be listening at thinking, you know what? I'm not on board.
I'm on board with all that stuff. Sure. So here is an even easier way. And, yes, a debrief is great. Just process the emotion, what you felt, dropping anchor. Great. I think the most basic one of all of these that, appeals to our prehistoric brains is a body oriented reset. So this is a simple way. After a case like you had in the trauma bay, you know, and everybody wants a PCU, step outside if you can. Mhmm. Look at the horizon. Shake out your arms. Shake just shake it out. Shake it out.
Shake it out. Shake it out. Let your body discharge energy because it's energy. It's stored up energy. Just discharge it. And this is not strong evidence, but there is even evidence that sprinting after these events can help integrate traumatic experiences. And these oriented resets are used in certain types of trauma therapy to prevent trauma from embedding in the nervous system. That's almost like a hack. And Yeah.
Some trauma practitioners, they do recommend intense short burst of exercise, like sprints, boxing drills, some kind of fast paced movement after a critical event. Discharge energy. That can be hard to do. Now running sprints in your clogs in the ambulance bay might be hard. Yeah. Yeah. I guess you could do some squats or or something. And so easier way is just, you know, get out, take it out, take a couple deep breaths. You can stretch or just walk around a little bit.
It's a a lower barrier still effective. I like it. Okay. So name it and ground yourself in the moment and or walk outside and engage in some active movement while looking at a horizon or something a little bit more calming and a little less stressful than the tracking board for a few minutes. Yeah. And don't bring your phone outside. Oh, yeah. So as you said that, I wanna bring up one more thing that I think every emergency doc would benefit from, and that is a post incident ritual.
I don't know what this looks like for the individual because it's very individualized and it can be tiny. And so the technical term for this would be signal completion. Because what you're talking about is you walk out of the room, you are not complete. You still have an open loop from that resuscitation. And that's what we're talking about with all this stuff. Dropping anchor. Let's reset our body.
A post incident ritual. So, you know, example, before I walk out of the trauma bay I well, I think you can see this on the video. Before I walk out of the Trauma Bay, I touch the wall, take a breath, and reset. And I don't know what's in my mind or in your mind at that time, but that's my ritual that I'm closing the loop on this, or I'm washing my hands. I am intentionally visualizing stress going down the drain.
Two examples of infinity. And what this does is it helps the brain close the open loop of what was previously an unresolved stressor. Yeah. Yeah. I love that. No. I like that very, very much. I wish that had come up in my last year of residency so I could have used it in practice. That's some great advice. And, you know, I really do think that the emergency department over time has become more and more of a pressure cooker. And we've talked about this before,
you and I, on the podcast. So this kind of information and these tactics, I think, become more and more necessary even in just the day to day shifts. I mean, so far, we've been talking about the trauma of patient experiences. But, honestly, some of my most traumatizing moments in the emergency department had to do with conflict with colleagues
and consultants, you know. Arguments I had over the phone or desperately trying to convince some specialist that the patient critically needed their intervention or that they needed to come in in the middle of the night and having some very uncomfortable conversations that, you know, sometimes it was less traumatizing to talk to a patient than it was to talk to a consultant. So it's not necessarily a trauma in the ED sense that brings about the
scenario. It could be a patient encounter, a call with a colleague, any one of those things. And then I also like that you said, you know, there's a difference between debriefing and just ruminating on a specific encounter because I'm expert at that. I have a advanced degree, a PhD in the rumination and the reliving of the moment. That's not something I recommend. You know, if you can avoid that degree, I highly highly recommend it. But that's something that comes back to haunt
me. Even now, I can look back on conversations I've had, you know, over a decade ago and relive them in a heartbeat or, you know, when I'm watching medical dramas on TV or seeing dramatizations of physicians having experiences, sometimes I just can't watch. I go, nope. This is reminding me too much of an encounter I actually had. When I'm talking with docs about this stuff and, you you know, you're talking about the locked room for the giant stuff sack.
Yeah. We have been talking about these big t trauma events and these things that just seem to have this massive footprint. Ninety nine percent of the time, it is accumulation of those lowercase t traumas, such as incivility from a colleague or something with a patient. These things that are small yet accumulate accumulate accumulate, and those are the things that we stuff into that stuff stack. Oh, god. Again again, I had to have this argument. And you feel it, you know, even just even
I'm saying it right now. I'm picturing. I can still feel it physically. And that stuff needs processing and attention because it will accumulate and is way more likely to burn you out than the mass casualty you see once in your career. Yeah. And so in that processing so you've got the in the moment event you've got the in the moment activities you can perform. You've got the post moment activities you can perform. You've got your driveway debrief that you can perform.
And then with the failure of all of those things, then you certainly have other resources. Right? I mean, you can seek out therapy or trauma therapy or other resources outside and away from work to try and deal with those things in order to either prevent or treat the repercussions of just our routine work. Right? So you can tackle it from all angles. I did not do this, but I think that every emergency doc would benefit from having a therapist
who specializes in stuff like this. I'm not talking about a general therapist, but a trauma therapist Yeah. From day one of residency. It maybe adds up a cost, but being able to work on this stuff will extend your career and just help you process the stuff. Just help you process all of this that comes at you in this supranormal environment. Mhmm. And I'm saying, hey. Therapy. Therapy. Therapy is the answer. Okay. Well, maybe it's not a therapist, but at least a system of
how you're gonna do this. And, you know, we're talking about the difficult consultant and all that. Having an approach to things is going to be better than not having an approach. So when there are things that stress you out, such as a critical neonate or a mass casualty or incivility from a colleague, building up pathways and having the confidence that you know what to do in these situations is going to serve you from a trauma standpoint that, you know, how you frame
it in the moment. The story put that, oh, I can navigate this. You know? What this joker, I can handle this versus, oh my gosh, there's gonna be conflict, and I'm gonna feel like an idiot. And all this toxic the inmate comes in. I got this. I know what to do. These are sick patients, but I'm prepared versus I am unprepared. Being prepared, having pathways, that in and of itself is protective.
Yeah. Yeah. That's a great point. You know, I never ever in my career thought that having a pathway for how to deal with a resistant consultant would have been something I needed. But absolutely, that would have made so much of my practice easier to have that, you know, the little button you push go. Oh, this person's being difficult. I'll just push this button, and I'm gonna walk down this road of questions. I see you don't want to come in in the middle of the night.
Let's talk about why I'm calling. And then, you know, answer yes, answer no, answer no. Okay. Yes. I can see why you have understood it to be that case. However, let me go back to the patient that I am talking about. You know, it would have been so much easier to be like, I need a call center script for how to deal with this consultant in the middle of the night. Would have made my life
so much easier. Okay. To that point, and it's gonna sound like a shameless plug, but I have to put in the context of story. Every cohort of Unburnable, this happens. What you're talking about, we have basically a month on navigating difficult consultant and communications, and it's about this stuff. And what happens is a lot of docs this is the thing that brings misery to their career. And then they've learned these tools, and they can't wait that doc to start giving a bunch of crap.
And they're waiting like a panther in the night to pounce and not pounce in a bad way to say, oh, I'm gonna shove it right back in your face, but, oh my gosh. I can see what a joke this is, what a joker you are with these things. And, you know, this is compassionately towards the other person, but I'm so excited to be able to deploy these tools.
And you think about that, Sarmad, and just apply that to anything that you do in medicine that, oh, I'm so excited to deploy this tool of communication, of I know how to get vascular access on this critical patient. I'm excited versus I freaking read this is about to happen. Woah. How different are those careers? Yeah. Yeah. That's incredible. That is incredible. Alright. Tell me the name of the course and where someone can go to learn more. Okay. So when you find all my stuff at RobOrman.com,
that's one on one coaching. That's the unburnable course. Unburnableunburnablecourse.com, or or you can just go on my website. There's lots of different places to find it. And we've got a podcast and lots of free resources specifically for emergency docs to address pain points that come up in clinical practice. Absolutely. And those links will be in the show notes. There is so much more we could
say on this topic. But if you're listening and you work in the emergency department, I just want you to know that much like your continuing medical education fills in your knowledge gaps for treating patients, you need something in this area to complete your practice and your knowledge so that it will encourage your career to be as long and as fulfilling and as joyful as it potentially can be and prevent that
burnout. Or as I tried to explain this to my teenage daughter, what it's like to invite someone into your massive mansion of a home and say, hey, welcome. Come inside. And then the person walks into a room that looks like a small bathroom with some white walls and a window. And they go, where where is the rest of the house? I mean, this place is a mansion. Why am I standing in this teeny little room? And I go, oh, this is where I live. And they'll
say, well, what's behind that door? And I go, oh, yeah. I've been cramming stuff in there for decades. There's no space left in the rest of the house. So I live here in this little room. So if you wanna enjoy your house and your home and all of the spaces that you are supposed to have for the long, long life that I hope you live, then you need to have these skills. And I'm happy today that there's a place you can go to get them, and there's
always other resources out there. So devote a little to talk to some colleagues. Go to roborman.com and take a look at the resources. But do yourself a favor and partake in those things as soon as possible. I love that metaphor, Sam. You told me that before we were recording, and just picturing you standing with your arms at your side with no room to move around. That's right. It's fine. That's what it's like. Welcome to my mansion. Welcome to my mansion, my castle.
Wait. Why are we in this room? This tiny little place. I'm sorry. The rest of it is just jam packed to stuff I've been cramming in there for years. Oh, my goodness. Well, doctor Rob Orman, thank you so much for being on the podcast. Once again, the contributions are so enlightening and so important and so career transforming. If you're listening, again, I can't recommend it highly enough. Go check it out, robwormon.com. Rob, thank you so much for being on the show. Always a treat, my friend.
Well, ladies and gentlemen, that's the end of today's episode. Thank you for joining us. Don't forget about ebmedicine.net, your one stop shop for all of your emergency medicine and urgent care medicine needs. This month, we've got a free antibiotic guide for you when you subscribe, and we are releasing the new and improved version of the laceration course, and you can find out more about all of those things, as always, on the website ebmedicine.net. Until next time, be safe everyone.