How about some time off to reflect?

It’s 8pm and the charts are piling up in the ED – you notice the resident appears tearful.  A probe reveals that she just found out her grandmother passed away.  What do you do next?

Reflecting back on my year- i can recall at least a dozen times a co-worker or trainee on a shift was sick with one of the following:  diarrhea, vomiting, cough and sneeze, strep throat.  Or had an acute personal life-event: relative passing away, sick child, sick parent, wife going into labor.  And then of course there is the emotional impact of our patients- and the patients whom we could’t (or didn’t) save.

In poker the term “on-tilt” refers to the change in playing behavior seen after a big loss (or big win).  Being “on-tilt” is not good, as one should in theory base their moves on the winning odds from the cards in their hand- and emotions do not change odds.

In medicine we constantly face the challenge that our past cases can influence our future decisions (it’s not all bad since heuristics are a huge part of the art of medicine) but there are inarguable circumstances where the odds should dictate our choices- and yet our current emotions or past experiences negatively impact our management.

This is only compounded during periods of high personal stress – so why are we so behind other front-line fields in coming up with a system to deal with it?

The concept of rotating people in and out of the “front-line” dates back (at least) to Roman times- where the science of optimizing the performance to stress ratio was trialled through various fighting configurations.

Firefighters have an entire policy on how to establish a “rehab” tent on site for long duration.  Of course, some might argue anecdotally that firefighters are similar to us in the midst of an emergency – often breaking rules on overtime, etc. in order to get the job done.  But unlike us- there are formal documents outlining how to recognize and care for physiologic distress in themselves and their colleagues.

Rest and recovery stations are setup to provide- nourishment & rehydration.

“This ensures that physical and mental condition of members does not deteriorate to point that affects safety of each member or that jeopardizes safety and integrity of operation”

Staff constantly bring candy and snacks to share at work (I’m that guy who brings bananas) but imagine if this was provided systematically by the hospital as part of a best practice approach to keeping the frontline providers “well nourished and hydrated”.   No offense to JCAHO – but I feel that they have reinforced a culture of throwing out coffee cups and water bottles based on an OSHA rule intended to protect workers (from contaminating their coffees with germs); instead of truly protecting workers through promoting rehydration and nourishment as practices that are best for us and therefore for our patients.

Thankfully, we are getting better at defusing and debriefing after critical clinical events.

The culture of critical event debriefing is slowly making it’s way throughout the country.

Driven, in part, by simulation programs and safety culture- many EDs are making critical event debriefing part of their routine.

Firefighters and military routinely “debrief” after an event, typically utilizing the After Action Review method.

What was our mission?

What went well?

What could have gone better?

What might we have differently?

Who needs to know?

I would add that we need somebody whose role is specifically to assess and address the psychological needs of those involved in the event.  Yes- dealing with crisis is our business, but some cases are not business as usual.  In those unique situations we need to make it more routine to remove people from the frontline to recuperate or risk that patients will be impacted.

In NY I remember riding with the fire company and learning that after being involved in a fire- the captain often mandates personal leave for those who “saw action”.  There are similar “shore leave” policies in the military.  Some of the men and women were upset at being benched – but this just underscored why it needs to be an authority figure who forces us to take care of ourselves.


The culture of bravado is a byproduct of the stress we face each day- and it is not easy to tell a PEM doc to go eat, or go to the bathroom, or call-in sick.

As for the resident whose grandmother passed away- I insisted she take a walk/ take some time to reflect and go home if needed- and only got her to agree by saying she could pay it back to her trainee one day.  Until the system catches up- it is up to us to work on changing the culture one day at a time.

Share your thoughts, ideas or stories below!


David Kessler

David Kessler

Director of Clinical Simulation and Pediatric Emergency Ultrasound at Columbia University Medical Center
David is also the research director for INSPIRE (International Network for Pediatric Simulation-Based Pediatric Innovation, Research, and Education). Outside of work, he enjoys spending time with his family, tae-kwon-do, saxophone, and musical theater.
David Kessler

Latest posts by David Kessler (see all)

David Kessler

David Kessler

David is also the research director for INSPIRE (International Network for Pediatric Simulation-Based Pediatric Innovation, Research, and Education). Outside of work, he enjoys spending time with his family, tae-kwon-do, saxophone, and musical theater.