Our Guest: Mitchell Radin, PsyD, LP, Psychology Manager of Hennepin Healthcare’s Critical Incident Support Team
Mitchell is a trauma informed specialist. After years of working with people in high trauma exposure jobs, Mitch came to recognize his way of dealing with that regular exposure was unhealthy. This realization spurred him toward the development of a great program that impacts healthcare professionals on a daily basis. He teaches them how to respond to the everyday stressors of healthcare. The result, a more appropriate daily response which decreases the impact on their bodies and minds and less need to turn to substances to cope. This is a great episode and will give you some things to think about for your facility as well as yourself!
Transcript:
Terri
Welcome back everybody, today’s episode. Our sponsor today is IMI. IMI is the manufacturer of the industry leading prep lock line of tamper evident caps, which are an active deterrent to diversion. This is just one more tool for you in your tool belt when it comes to diversion, mitigation, and monitoring. My guest today is Dr. Mitchell Raden, the Psychology manager of Hennepin Healthcare’s Critical Incident Support Team and Adult Psychology consult service. That is quite a title. I hope you have a lot of people under you because that sounds like quite a job. He’s doing some really interesting things with healthcare professionals and coping techniques to decrease workplace stress. The kinds of stress healthcare professionals see on a daily basis that make them more susceptible to turning to substances to help cope.
Terri
So we need to find ways to redirect that and address those issues before the disease manifests itself. Mitch is going to be sharing some ideas with us that hopefully we can take back to our facilities. So welcome, Mitch. I am so glad to have you here today.
Mitch
I’m so happy to be here today. Thanks for having me on.
Terri
Let’s start with a little bit about your background, what type of work you’ve done in the past, as well as a picture of the facility that you are now part of.
Mitch
Okay, so I started my career in the California Bay Area on a mobile crisis team. So right out of grad school, I got hired onto this mobile crisis team that works alongside police and fire. Got called out to situations in the field where first responders determined that there was a mental health component to a call that they were brought to. Or they showed up somewhere and realized that there was somebody who was deeply traumatized by an event. And my team would go in and provide on the spot support to mitigate the crisis and get people kind of back on their feet. The other part of that job was to facilitate critical incident stress debriefings for police officers and firefighters following really distressful events.
Mitch
So those were these formal, typically between one to two hour processing sessions where we could go through these steps to kind of help organize people around what happened, bring people back to a state where they could kind of metabolize the experience, reorganize as a coherent team, and send them back out into the world to do what they needed to do. What I realized though is that was a very small part of the support that I was giving, because what started to happen very early on was I started to notice that police officers, firefighters, were experiencing a lot of stress and distress related to some of the calls that they were on. I mean, they’re going from stressful event to stressful event and at no point are they able to ever fully move into a relaxed state.
Mitch
They’ve got that police radio in their ear no matter how loud the environment is, no matter how chaotic it is. They could be having a cup of coffee and be super chill and all of a sudden they hear their call sign and they mobilize into action. So there’s always a little bit of their brain that’s taken up with kind of attuning to the next moment that might happen that has a corrosive effect over time. I did that work for many years and we can talk about some of my responses to that. But what I think I will say up front, part of why I got really interested in navigating and helping other people understand how to navigate really complex internal sensations in the context of exposure to really chronic stress is because I wasn’t aware of it.
Mitch
And I wasn’t aware of how I was being impacted by spending 40 plus hours of my week going from really stressful situation to really stressful situation. I was excited by it. I was young. It was all adrenaline filled. I was getting to see and kind of be exposed to and invited into all these environments that were really unique and really exciting. And I tuned into the excitement, but I did not tune into how exhausting it was. And part of my job was to show up at scenes where somebody had died. So some of those were suicide, some of those were natural causes, but you’re showing up and people are distressed reasonably. And I had a period of time where I think in one month there were like five death situations that I had to respond to in a pretty close succession.
Mitch
And I went home one day and sat down to watch it. It was the Super Bowl, actually. And I sat down and felt completely empty. I had nothing in me. And I was like, I do all this really interesting, amazing stuff and I feel no connection to it. I feel no connection to the world. I didn’t want to call anybody. I didn’t want to do anything. I wasn’t paying attention to what was on TV. I was just sitting there. That scared me a little bit. And I realized in that moment I needed to really do something different, not with my career, but really paying attention to what I was enduring on a regular basis and figure out how to navigate it. So that’s kind of the did that for about 16 years.
Mitch
So obviously I figured out some way to manage it, which we can talk about. But then we moved to Minnesota in 2014 and I got hired at a home health agency for nurses who went to people’s homes. And I was hired to develop a behavioral health component to the work that they were doing and really help the nurses understand that the mental health issues that people were dealing with were impacting their physical well being and their physical well being was impacting their emotional well being. But what I realized when I started is that I didn’t really know a whole lot about nursing culture. So I started to do this deep dive into nursing culture and everything that came up was nursing and burnout, nursing and compassion fatigue, nursing and bullying, like all of this stuff that was just this toxic brew of stress.
Mitch
And so I started to organize what I was doing as much towards developing infrastructure for nurses to process this stuff in groups and individually as I was helping them organize around how to address some of the mental health issues that were coming up for people. About two years into working there, we got purchased by this larger hospital system, hennepin Healthcare, hennepin county medical center at the time. And I ended up getting hired into this position as critical incident support team manager and psychology consult service manager. So it used to just be the psychology consult service. We didn’t really have any meaningful framework for real crisis response for staff here. We had a system that was set up where people could submit a request for support following a really stressful event.
Mitch
So a bad outcome where somebody died, somebody was assaulted and the whole team was impacted. But it was a really wonky system and it was typically a day or two before somebody was able to respond and coordinate a meaningful response. And what we found is nobody was using it. I mean, in the six months before I started the position, I think there were like five or six requests for support when we knew that there was a ton more going on, but nobody really knew how to use the system meaningfully. So we had the psychology consult service. So this is a small team. I have five people right now who get consulted by physicians throughout the hospital.
Mitch
We go bedside and provide kind of trauma support to people who’ve just been through maybe a car crash or gunshot wound or some other thing that they’re really trying to figure out how to organize around the experience and manage their acute stress symptoms while they’re dealing with all this medical stuff. Then we give them the immediate support and then we give recommendations to the providers to help them provide support and kind of continue to do the work to support the people with their mental health symptoms or acute stress symptoms as they’re coming up. What became really apparent about these consultations, too, though, was that a lot of the referrals that we’re getting were really born more of provider stress than they were of actual need from the patient.
Mitch
Because it would be pretty normal for a lot of patients to be crying following the death of a loved one or being in some critical car crash Where their bones are broken. But for some reason staff would be very concerned if somebody was crying, feeling like that was too much to deal with. And so they would have psychology come in not realizing that we just need to support a normal response and not pathologize it by having a psychologist come in to offer that framework and support. And I’m always open to going in to give that support.
Mitch
I always want to go in to give that support, but I want to make sure that this person could use some support right now and some framework around navigating what’s going on and not in service of just alleviating the provider’s distress because they don’t know what to do. Does that make sense?
Terri
Yeah. If I’m hearing you correctly, the healthcare professional either maybe because they were burnt out and they didn’t know how to deal with it, or they didn’t want to deal with it. Referred them to you as a kind of a let’s be done with this and turn them over to the psychologist for help? Or just that it made them feel so bad and they didn’t know how to handle being in the room with them that they turned it over to you or both.
Mitch
Exactly. Okay. Yeah, I mean it’s that confused, I think.
Terri
Interesting.
Mitch
Everybody is submitting consultation requests with the best of intentions and I think everybody’s really operating in a meaningful way when they do it. But I think it is really confusing for people because there is so much stress and distress. And when we see somebody in distress, we’re not just seeing somebody in distress, we’re having a mirrored response to that distress. And if you’re holding all kinds of distress that you’re not able to acknowledge or are trying really hard to push down, you want to do anything you can to organize around that and get away from it. And that is a completely adaptive response. And so I don’t blame anybody for doing that.
Mitch
And again, I think most of the referrals we get are really appropriate, but I think often there is this little bit of edge of I need somebody else to hold this anxiety for me because I can’t.
Terri
Interesting. So did your program kind of then start out to be where you’re going to the bedside for the patients, but then it made you realize that our staff needs support and is that how the program grew?
Mitch
Yeah, we had been aware of that and we knew that we needed to revamp the whole critical incident support structure within the hospital because we can talk about the context of it in a minute. But we knew there was a lot more going on, people way more distressed and needing support, but nobody was asking for it and didn’t know how. So it seemed apparent to me that if there was a really accessible system, people would use it. And so what we did was just set up a pager system so that anybody who experienced anything that felt overwhelming in the moment, that they felt like they needed any kind of support around, whether it was somebody being assaulted or again, witness to a code that went sideways or really bad interaction with the patient where they got yelled at, they could page us.
Mitch
So we’re a team who’s already on the floors. We’re running around talking to patients so we can be accessible to people anywhere between five and 20 minutes depending on whether or not we’re with a patient. So we set up this system where people could page us. We would go running to wherever they were or call them if they preferred a phone call, whatever it was on the page that they requested and offer support in real time. The other part of that was managers or leaders in a particular area could page us directly and we could get back to them right away to orchestrate a larger response if they needed it. So we’ve had a number of situations in our jail. We have staff, Hannah Penny Medical Center and healthcare kind of branches out to all sorts of areas.
Mitch
So we support the medical needs in the jail. So we had a number of situations in the jail recently where were able to, same day, within a couple of hours, get to the jail, organize, debriefings and diffusings for people to help organize around the distress of it to help mostly just normalize responses for people and give people framework around what they can expect so they don’t feel so crazy as they’re feeling this stress and tension.
Terri
Right, okay, interesting. So pretty comprehensive program then for staff and patients alike and how they’re actually intertwined maybe more than we realize. And so I’d like to talk about some of the things that you do or the methods that you use. And I think it’s also important to talk about how did you get them to participate because I would imagine at first it might have been a little bit slow going to actually get them to call you. When we talked previously, you mentioned something that I had never really thought about but I think is so true and that is when you’re involved in an incident, I may be feeling something but I look around to the rest of the people in the room with me and everyone seems to be handling it just fine.
Terri
And I’m feeling like is nobody thinking that this was kind of a big deal? Everyone else looks fine, meanwhile everyone else that looks fine. There are probably one or more in there that are thinking just like I’m thinking and they think I look fine and I am not making a big deal of it. And I think I shared with you the very first time that I was in a cold blue situation in the Ed as the pharmacist at the bedside and the outcome the patient didn’t survive. And so this is my very first time in this situation. And they call the code and the physician, anybody have any objections to calling the code and nobody says anything and I didn’t have any objections. We’d been there for a while.
Terri
I don’t know what else we could have done, but it’s like you’re asking me to take part in this. Yeah, okay, go ahead, call it. And then everyone packs it up and they leave. And it was like, what my first experience? So I didn’t overly dwell on it, but it certainly went through my mind a few times. And obviously, 35 years later, I still remember it. It was the first time. So I think it’s very true that everyone looks like they’re handling it, but there’s more people that aren’t.
Mitch
Yeah. And that’s the toxic sludge that we’re all trying to operate in here. And I think that’s the scariest part about it in some ways is that so we are trained as medical professionals to just be professional. We throw up with this professional facade, and we do not show distress. That is a failure in the minds of many medical practitioners. It is seen as a weakness. And I cannot tell you, I actually don’t know that I’ve ever spoken with somebody as a resident or who was talking about their residency that wasn’t shamed for having an emotional response at one point.
Terri
Wow.
Mitch
And especially for women. Nobody’s going to take you seriously if you’re emotional.
Terri
Yeah.
Mitch
And so people really learn that they’re supposed to push down and essentially dissociate from their internal states of distress. And if you think about medical training, residents work 30 plus hours without a break, without a lot of sleep. They’re hungry, they’re thirsty, but they don’t eat and they don’t drink. And they’re expected to operate at really high levels of functioning and performance. They are literally learning to dissociate from their internal states of discomfort. And what I would say about that is that we can fragment off all of these uncomfortable feelings and sensations, but they don’t go anywhere. They’re fragmented off. They’re put somewhere safe for the moment so that we can function, but they’re just waiting to express themselves. It’s not like they evaporate. That’s when we start getting really confused because I can fragment this stuff off.
Mitch
I know how to operate in this context of intensity and chaos. But when you leave that context of intensity and chaos, suddenly you start reacting in ways that you typically don’t want to. You’re more irritable than you typically would be. You’re lashing out at people. You don’t want to see people. All you want to do is sit down and have your glass of wine at the end of the day and tune out. You do anything you can to sort of avoid this, but you’re not engaging the world in a way that you typically would, because that fragmented, off point of distress is still needing to bubble up.
Mitch
And this is the problem that I think a lot of people face, is that in the context of hospital work, in all of the intensity of what people face in medicine, they’re churned up inside and their internal state of chaos is matched by the external state of chaos. So that feels normal. But as soon as people go home, no longer does the external world reflect what’s happening inside. And now that’s really confusing. I’m super churned up, but this world is really different and calm and I don’t know what to do with it anymore. So the only place I ever feel normal is at work. Now when I go home, I have to do something to tamp this down and feel like I’m regulated because my family is irritating the crap out of me and I want to just be alone.
Mitch
Or I want to be out in the world doing really life affirming and adrenaline filling things that may not be the most functional as far as sustaining relationships and being grounded in the world. So people find other ways to do it. That regulation.
Terri
Okay, so I do want to talk about how did you get the group there to participate in your program and some of the things you do. But before I forget, I want to ask you, we’re talking about the person that now goes home and they need to find a way to kind of settle that. Do you have recommendations for the spouse or the people at home that are living with somebody that is in these situations? Would you recommend, I don’t know, making sure that they have that hour to themselves as opposed to just like jumping in with the rest of the family the minute they walk through the door or obviously giving them an outlet to talk, but if they choose not to talk, do you have any recommendations there?
Mitch
Yeah, that’s multifold. And so I actually will start then with hopefully I won’t lose my train of thought, but I’ll start back with the original question around how I got buy in from people before kind of taking the position as the critical incident support manager. We had been doing a lot of work around trauma informed care like education throughout the hospital. Me and a very small group of people had started a four hour class, some training that we got from a place called Trauma Transformed in the Bay Area. We went out and got trained by them and then we used a bunch of their material to set up the training here at the hospital.
Mitch
So I had been speaking with a number of different groups throughout the hospital system and just kind of random people who showed up to the class and people started to kind of get a lot of the trauma informed stuff that I was teaching wasn’t just about kind of understanding trauma in the patients that we see. It’s about that escalation of stress that we accumulate as healthcare providers that changes the filter through which we see the world, which promotes a greater sense of reactivity. Because as we are exposed to more and more stress, we start to become more and more adapted to tune into stress and distress threat at the expense of safety and calm and all that stuff. So I offered a framework around that. So when I’d already been kind of a known quantity in a number of different areas throughout the hospital.
Mitch
And so when we started to kind of message out that this was a thing, I gave a talk at, I think, maybe the clinical grand rounds and to our leadership group and some other areas to really kind of pitch it and give them a framework for it. Many of them already heard me speak, so they kind of knew what they were getting. And then very quickly, people our pagers started to just go haywire. And so since we started this program a little over a year ago, within the first year we had 200 and I forget what it is now, 230 maybe, requests for support. Those are the ones that we actually documented, right? But it just became word of mouth as individuals were getting support and realizing that weren’t documenting anything, it was strictly confidential.
Mitch
We were just there to offer really kind of basic support and normalize people’s experiences. And then the debriefings that were doing where people actually recognized that they didn’t know how to navigate the distress of this stuff, and we offered a really basic framework to do that. And then we would hold sometimes office hours. So if there was a whole unit that was impacted, one or two of my staff would just go kind of hunker down, and the nurse manager would then hold space. So if one of the nurses wanted to come in, they would take over for that nurse. While the nurse came in to get a brief support, they would come back out and send the next person in. And so we’ve impacted lots and lots of people here, and it’s been really good feedback.
Mitch
So what I talk about regularly is and I also give talks throughout the hospital and stuff, but what I talk about regularly is that I want people to get paid to cope. I don’t want people to do all this stuff when they’re at home. It is mythology that we cannot take a minute to stop and take a deep breath. It is mythology that we cannot take a five or ten minute break. People show up to work three, four staff short, and all of the work still gets done. But we believe somehow that it’s impossible for us to take five or ten minutes to step off the unit, to collect ourselves, or to nourish ourselves or to pee or any of that other stuff.
Mitch
And when I talk with people about it directly, I’m like, does it really feel like it’s true that you can’t take a break even in the most intense areas like the ICUs and the Ed? Or is it really part of that mythology, that belief? And every time people are like, probably the mythology, it’s probably not actually true because people do take time when they need to, and they recognize that they can function when they’re short. It’s not pleasant. So what I talk about is, like, helping people understand their own neurobiology, their own physiological responses to this stuff, such that they can mitigate the impact of that stress that they’re experiencing throughout their day. Not allowing it to escalate. Escalate. But escalate level off. Escalate level off. Escalate level off. And we can talk about that a little bit.
Mitch
But when people do that and they have the framework, they’re constantly moving then from this place of reactivity to a place of intention rather than reactivity to, reactivity to, go home to be reactive, okay? Doing is just positioning people to be a little more intentional about how they’re operating. If they can do that and they’re managing things and they’re owning that it is normal and appropriate to experience stress in the context of health care, we can’t avoid it, we can mitigate the impact of it. But if we just own that it is stressful and that we are going to be impacted by it now, we can actually do something with it, but if we’re just ignoring it and pretending like we’re not impacted by it, we’re going to be at the mercy of it and we’re never going to get through it.
Mitch
So what I talk about with people as we help them individually organize around it, we talk a lot about how you cannot manage this stuff alone. We’re not designed to be these hermetically sealed units that operate in isolation. We need other people. And so finding ways that work for each individual both while they’re at work to get the support that they need, and at home, it looks different for everybody. So what I talked about, and this is a strategy that I got from a guy named Eric Entry, who teaches a lot of he does a lot of work around provider wellness, that kind of thing. But one of his strategies was set up a contract with your partner, whoever you’re at home with or your best friend or whatever.
Mitch
I will never talk to any medical professional who feels completely competent or comfortable to go home and tell their partner or friend everything that they did at work. Everybody smiles and shakes their head that they’re worried about traumatizing everybody. So even more, it’s like, I have to hold all this stuff. But you don’t. And your partner wants to be there for you most of the time, right? So the strategy is to go home and have a conversation with them and write up a contract. Like, okay, so when I come home and I’m having a day and I need to talk, this is what I need from you. I need you to listen without kind of interrupting me. Unless you have a clarifying question, I do not want you to tell me.
Mitch
It’s going to be okay, please do not give me a hug unless I ask for one.
Terri
And do not try to fix anything.
Mitch
Do not try to fix anything. Just hear me out for a minute. And then what you’ve done in that moment when you’ve really laid out that framework is you’ve taken all the anxiety out of it for your partner. They know what to do. There’s no mystery behind it. There’s no gymnastics they have to do to figure out how to respond to you.
Terri
Yeah. What do I say?
Mitch
And so what then happens is you get to talk to the partner or friend or whoever it is about. What do you need? What are the details that you can handle? What kinds of things I go elsewhere for? What is your bandwidth? Can I go beyond ten minutes or not set up the framework so that you know what the other person can handle, because we’re always worried about traumatizing the other person. So take it out of the picture and then figure out a framework to wrap it up and move into the rest of your day. But that communication is really critical and to just own it and give somebody permission. I pay attention to this stuff all the time. I am hyper aware of my own internal states and navigating the tension in my own neurobiology throughout the day.
Mitch
And a couple of weeks ago, I went home and my wife said, we have to talk. And she said, Your presence at home has just been really thin lately. And I’m like, yeah, you know what? You’re right. I didn’t take it as an insult. I knew she was right. It was like, okay, I got to figure out a way to recalibrate and do something different because I am tuned out at the dinner table. I’m exhausted when I get home, and I’ve been supporting people all day. I’ve got nothing left for my family. That’s not acceptable. So I really had to kind of do a lot of work to kind of self reflect and figure out how I was going to start to manage things differently at work. So I could be both the psychologist at work and the father and husband at home, right?
Terri
Yeah, that makes sense. I think what I’ve heard you say a lot of the beginning of all of this is just recognizing that there is that trauma and stress at work and that we are going to respond to it in some way. And that we have to learn how to recognize that we’ve been in a stressful situation and then start to manage it rather than just ignoring everything.
Mitch
Exactly. And I think that’s the thing that I think, again, we’re taught all of these really amazing clinical and technical skills, but nobody teaches us how to do the emotional heavy lifting of this work, and yet we are doing extraordinary, herculean type emotional heavy lifting. We’re engaged with people at the worst moments of. Their life, giving them the worst news of their life, like doing all this really horrible stuff. We dig it. We know how to do it. We’re excited by it. That’s awesome. And we need to be attuned to all those other mechanisms that are happening as we’re kind of doing that work because it is corrosive over time. And what this narrative in healthcare is that we’re all traumatized. I don’t know that we’re all traumatized.
Mitch
We’re all experiencing in my framework and the way I think about it, we’re all experiencing these really intense repetitive stress injuries. I’m not big into sports metaphors, but if you think about a pitcher who’s pitching a ball for nine innings, their shoulder is going to experience some pain and inflammation by the end of those nine innings. But that pitcher is aware of that. That pitcher is going to do everything between games to ice that, keep that joint healthy, to optimize the muscles around that joint and be able to go back out there to perform at optimal performance. We as healthcare providers ignore that. We just let all these muscles atrophy around taking care of ourselves.
Mitch
We don’t do the work to kind of optimize that nervous system, tolerate these repeated assaults on that kind of sympathetic activation in the moment of code or that shutdown response when something goes really sideways or we’ve had a really bad day, or we just talk to a super depressed patient. We don’t do anything. We just pretend like we’re going to move through it. And so one stressful experience on top of another stressful experience accumulates over time. We end up with the equivalent of these repetitive stress injuries in our nervous system. And that expresses itself exactly like trauma. It’s not just one event, it’s exposure to event after event. And again, when I say that I want us to get paid to cope.
Mitch
It should be 50% of our job to be attuning to our own internal responses during the workday so that we are meaningfully attuned to our own well being, which is only going to optimize our attunement to our patients and help us operate at peak performance. Because our executive functioning is going to be optimized if we are optimizing this system.
Terri
Okay, that makes sense. You may not be into sports metaphors, but I think that was a great one for what you’re trying to teach. So how do you do that then? So you get people to recognize that this is trauma, this is repetitive stress injury. So deal with it at work. Don’t wait until you go home. But what are some of the things that people can do? And I’m sure like any kind of mindfulness training or what have you, this takes practice. It’s not going to like just you’re going to tell somebody what to do and they’re going to be like, oh my gosh, this made such a difference. I get it. Now. But what kinds of things do you talk them through or recommend that they practice?
Mitch
First things first. I tell people to stop trying to think their way out of their distress. The brain is not the primary decider of whether or not we’re stressed. Our brain and our body are in this constant feedback loop. And what people mostly don’t acknowledge or recognize is that of this feedback loop of these nerve fibers that go back and forth from brain to body and body to brain in our autonomic nervous system. Ten to 20% of those nerve fibers go from brain to body. 80 plus percent of these are sensory nerves that go from body to brain feeding your brain information about the world. So if I’m holding tension in my body and my heart rate is being fast and my breath is tight and shallow, my brain believes that I’m being chased by a predator.
Mitch
If I am holding my breath and kind of frozen in space, my body believes that I am caught by a predator. Either one of those is a stress response, sending a signal to my brain, throwing my prefrontal cortex offline, optimizing me to respond to threat at the expense of everything else. And so the easiest way to think about it is like if you think about your brain like a rider and a horse, your prefrontal cortex, that executive functioning, thinking part is like the rider on the horse. It’s the intentional part that takes us where we want to go. The limbic system or that amygdala, that emotional part of our brain is like the horse. It’s the emotional beast that takes us from place to place when everything’s operating the way we want it to.
Mitch
The rider is planted firmly on the horse and we are meaningfully engaged with the world in a measured way. But if a threat moves in front of that rider and horse, if a horse throws the rider because the horse does not need the rider in a moment of stress or threat, the horse needs to react and respond to that threat. The problem is we typically never know that our rider is off our horse because under conditions of threat, we are so hyper attuned to that threat and so analytically accurate about what’s happening to save ourselves, that we think we’re thinking really clearly because we are thinking clearly about the threat, but that’s at the expense of everything else around us.
Mitch
So if I’m being chased by a bear, it’s not really adaptive for me to be thinking about how beautiful the leaves are in the trees. I’m just thinking about the bear. So that’s great. I’m chased by the bear, I get away, my system goes back online and my rider gets back on my horse. But if that bear is around every corner poof. Little bit. My rider’s off my horse. Now it’s behind me as I kind of driving to work. It’s chasing me. Poof. A little bit more. I go to work around every corner, every room I go into, there’s that bear waiting for me. Poof, poof. I am more and more optimized for that ride. I would just be barely hanging onto that horse, and my horse is now optimizing.
Mitch
The thing is, I don’t really understand what’s happening in my neurobiology in that moment because I’m still thinking clearly, I can do my work. But what’s happening as I’m doing my work is I am more and more attuned to the fact that I have no resources. I am frustrated with the system. I am frustrated with this patient. I am interpreting more and more interactions of being threatening and stressful. I’m feeling less and less agency and a greater sense of hopelessness around my ability to make a meaningful impact. But you still have all these really extraordinary skills. You’re still able to do all this amazing stuff, and you’re not tuning into this amazing thing I just did with this patient. I just made that person feel so much better. I’m not really thinking about that anymore.
Mitch
I’m not really able to register that because my body and my brain are not adapted to attune to that. My brain is still scanning for the threat and the stress. And so you leave and you feel like, I just couldn’t do everything I wanted with that person. I have to just go on to this next thing. Now I have to document, oh, my God, this documentation is so horrible. And it goes on and on, but you lose contact with so that muscle that allows you to be attuned meaningfully to the world starts to atrophy over time. And so I’ll make this part very brief here again. What throws our rider from our horse or not is our body. And I won’t go through the whole nervous system like thing, but your heart is literally the control mechanism of your stress response.
Mitch
It is the social engagement mechanism. When you are really regulated, your breathing is even and open. Your heart rate is kind of at a normal pace, and it’s sending a signal to your brain, you’re cool, you’re fine, everything’s good. Get your rider on your horse and go for it. When your breathing is tight and shallow or you’re holding your breath and your body is holding all that tension, it’s sending that signal to throw your rider from your horse. So what I talk about with people is you can’t control your stress response or whether that rider is on that horse just by thinking about your heart rate and changing your heart rate. But you can control it by controlling your breath. Your lungs are connected to your heart. So when you breathe in, your heart rate goes up a little bit.
Mitch
When you breathe out, your heart rate goes down a little bit. And it’s the downbeat on that heart rate that literally changes the signal from body to brain that puts your rider back on your horse. Which is why when we’re frustrated, we sigh, and when we’re sad, we sigh. And when we’re sobbing, it’s our nervous system always trying to regulate us. But we ignore that. And so what I suggest to people is just pay attention to your heart rate, pay attention to your breathing. How do you know if your rider is on your horse or not? Check your body. If you’re holding tension and your breath is all kinds of wonky regulate that one. Slow, deep breath is enough to just interrupt your stress response.
Mitch
So instead of, again, just ignoring it, going from stressful thing to stressful thing, what I talk about with my trainees all the time is before you go in that room, check your body head toe. Notice how you’re holding tension. Check your breath, regulate it. When you’re in there, check your body. Notice your stress response when you forget what you’re about to say or feel flustered in the interaction with the patient. Check your body. Guaranteed you’re going to be holding tension in that moment and your breathing is going to be kind of wonky regulate it. When you leave, take one deep breath, go on to the next thing. Can I give you a quick metaphor thing? Okay. Yeah. So one way I talk about this with people a lot, that really puts it in perspective.
Mitch
If you’ve ever seen one of those nature programs where a lion is stalking through the tall grass towards a herd of gazelle, the lion’s moving towards the herd. The herd pops up, watchful for the lion. Lion finds its moment, lunges towards the herd, chases it down. Herd moves in one direction, but invariably the lion is successful at separating one of the smaller animals from the herd and tries to chase it down. For our purposes, we’ll let the gazelle get away. Okay, I know, but I feel bad for the lion.
Terri
They got to eat, too.
Mitch
This is a no win. So the gazelle gets off to a safe distance, but what you do not see is the gazelle go directly back into the herd. That’s an agitated animal going back in to agitate the rest of the herd, and the herd will reject it because that’s not safe. What you see is the animal go off to a safe distance, kick its hind legs, shake its body violently in an effort to discharge the toxic adrenaline, cortisol and other stress hormones it just endured and escaped from the predator. And then it goes back into the herd, allowing the herd to beat the regulatory process by rubbing up against it and licking it and doing all that other stuff.
Mitch
How frequently do we just go from one stressful thing to the next without ever acknowledging that we just escaped a predator or just dealt with something stressful, without being aware of how much of that stress from that previous experience we’re bringing into this next interaction? Eroding our ability to feel connected to and attuned to the meaningful work that we’re doing because our rider is more and more off our horse. And so for the purposes of your work, it’s like it makes total sense when nobody teaches us how to cope, when nobody teaches us how to navigate these complicated things, that we manufacture our own mechanisms to cope. And those manufactured mechanisms are completely adapted in the context of a traumatic or wildly stressful environment. When nobody teaches us how to do it, we have to come up with something.
Mitch
And so if drugs are available to you or you have access to something that’s going to allow you to work and stay connected and allows you to feel regulated for the first time in a long time, it’s not entirely maladaptive. It’s adaptive to manage the distress. It’s not adaptive in the context of work, but that gets muddy really fast when your rider is always off your horse and you can’t make good decisions. And so what I’m talking with people about is be aware of your own neurobiology. It’s different for everybody, but get a sense of what that feels like for, you know, how to start to figure out how to relax your system and navigate that neurobiology so that you can figure out what you can do to cope when you get home.
Mitch
And hopefully not as much as you would have to do if you never paid any attention.
Terri
Right. Fascinating. Fascinating. And I’m sure we’ve just scratched the surface. There’s a lot of people running around your institution taking deep breaths and maybe even saying, get away from me. Don’t bring that stress into here.
Mitch
Well, I do this whole thing. You may have seen it before. You put your fist up like it’s the brain. And if you have your fingers over your thumb, the front of your fingers is like the horse or like the rider. And the thumb, if you lift up your fingers, is like the horse. And so the rider gets thrown from the horse and you kind of throw your fingers out. So you have these people running around the hospital, like, throwing their fingers up all the time. Use your rider off your horse. You need to take a break.
Terri
Yeah, that’s good, though. Then they’re working together as a team in a productive way to remind if I’m not thinking about it, somebody else is maybe reminding me because they see I need somebody to remind me what I talk about.
Mitch
At Huddles with nursing staff is be aware of how much gas you have that morning when you go in or that afternoon at the beginning of your shift. Everybody should be checking in with each other. People who have more gas can be taken the more complicated cases that day. People who don’t can be kind of taken a little bit lighter duty in such a way that everybody feels better about it. Because now the person who’s taken the heavier stuff because they have more energy knows that if they don’t, somebody else is going to step in because they so it becomes this much more collaborative attuned normalizing experience of stress management. Because we really need to understand that it’s not a failure to cope. It is not a weakness.
Mitch
People are responding appropriately to the way their bodies and brains are impacted in the context of chronic exposure to stress.
Terri
Yeah, I like that. And some days you wake up and you’re just raring to go, and other days it’s just like, oh, just to get through this day. No, I like that. Well, this is fascinating and this is great work that you’re doing. And your healthcare system, I think, is probably ahead of many places and they’re so fortunate to have you. And the program that you’re working on, I can’t but assume that it’s making a difference. I’d be curious to find out if there’s any statistics that you have less turnover or less sick calls or if that has improved over the time of your program. Might be a little too soon to tell because it hasn’t been going on too long, but it would be interesting to get some of that data.
Mitch
Yeah. Anecdotally people tell me that they feel like it has kept them from quitting. I don’t know how I feel about that sometimes because.
Terri
Anyway no, I think it’s great. I mean, you’re prolonging the life of their career because you and I both know they quit one place because they’re frustrated they’re going to go someplace else, and in just a matter of time, they’re going to be back in that same type of situation, especially these days with the short staffing and what have you. I think, yes, there are some employers that are better than others in general, but I think overall, you’re going to experience many of the same things in this ICU versus that ICU. So I think it is a great thing to hear comments like that. Okay, great. Well, thank you very much for sharing that. It’s fascinating.
Mitch
Thank you.
Terri
And I want to thank all of our listeners. Please hit that subscribe button. And I want to thank our sponsor, IMI. IMI’s prep Lock brand of Tamper evident caps have become an industry standard for guarding drug delivery containers such as IV oral and Nfit Syringes IV bags and medication cassettes. Learn more@imiweb.com. Thank you, Mitch, and great information.
Mitch
Appreciate it.
