Stop Compartmentalizing And Start Safely ContainingJul 19, 2022
As an emergency physician, there are countless situations on shift that may be produce grief, anxiety, anger, sadness, or frustration. Most psychologists recommend that we lean into our emotions, “feel our feelings.” Unfortunately, this is not practical for many of us during our workday. During residency, the concept of what to do with these difficult emotions was never explained. There were some generalizations about the importance of getting together with friends and colleagues, to share and commiserate. Yet, how often, and how to do this without it turning into an unproductive venting session was seldom explained.
Over the last two years, I’ve been increasingly aware of how these difficult situations, in turn, create difficult emotions in me, and how they add up. The situations that lead to the emotions are often traumas, aka “Ts.” The little and big Ts create residue, which a word that resonates strongly with me. Have you ever left a shift, felt exhausted, sad, angry, and for at least a few minutes have difficulty remembering the situation or people that triggered the emotion? This happens to me frequently. I’ve started to figure out what is happening, and I have a few suggestions on what to do to process these emotions more quickly and effectively.
Let’s take an example. Imagine you are evaluating a 3-year-old child with several burns. The mom tells you that the burns occurred when a curling iron fell off the vanity. When you’re looking at the burns, they’re in several locations that don’t line up with the story. Ultimately, you know your job as a mandatory reporter is to report the potential abuse, and not to be the judge and jury for this case. You order the medication to treat the child’s pain. Social work is not available, and you are left to tell the mom that a mandatory report is being filed with child protective services. She yells at you, questions your motives and clinical acumen. The words are piercing. Intellectually, you know you’re doing the right thing, but the interaction was intense, and you feel anxious and hurt. As you walk out the room, a nurse comes up to telling you that room 10 is having more trouble breathing, you’re caught up in a resuscitation that ends with him being intubated and several emotionally-charged conversations with his family.
Of course, this occurs right at change of shift, and your replacement is extremely detail oriented and grills you about the plans on several of your other patients that you didn’t have time to follow up on. You feel ashamed for not being more prepared for turnover, but also frustrated that he’s not being more understanding of your rough shift. You walk out to your car, feeling deflated and exhausted, but the details are fussy from your fatigue. You think for a minute that it would be nice to chat with your friend Ann, she always “gets it,” but is 2 am. You get home, pour a glass (or two) of red wine, and flip on Netflix. 2 hours later, you wake up on your couch and walk up to your bed.
The next morning, you have coffee with your partner, and he asks, “How was your shift last night?” You reply, “It was hectic, you know more of the same.” You go for a run and think about your upcoming vacation. That night, you go in for another shift. Within a few minutes of your arrival, the nurse tells you that there’s a mom that upset at the triage desk and threatening to leave with her child, they’ve been waiting a mere 15 minutes. You’ve got 5 new patients to be seen in your pod, and one has a concerning EKG. You think to yourself, my department head said we’ve really got to get the “Leave without being seen,” visits down. You rush out front, and the mom is curt and makes a few snide comments. You feel anger rising in your chest. Intellectually, you know it’s frustrating to have a sick child and to wait in the emergency department, but you are so annoyed! Does she have no situational awareness, this is an ER after all! You went out of your way to see them, while you’re really thinking you need to check on the patient with the concerning EKG.
What just happened? In my case, when I’m well rested, recovered and I’ve processed the difficult emotions of the prior shift, I can show up as my best self, demonstrate compassion towards the frustrated mom and likely diffuse the situation quickly. I can task switch easily and let difficult interactions slide off more easily. But in this case, the mom that is frustrated about her child waiting and is rude to me, is not just about this interaction. I’m feeling triggered by the case I had the last night. This is really about the unprocessed emotion of the mom that yelled at me about filing the mandatory report.
What is the answer? In emergency medicine, and many other professions, we do not have the luxury to instantly process every emotion we have. Frequently, for our patients’ safety and the safety of those around us, we must compartmentalize what we’re feeling. In training, this was frequently described as “pushing through it.” We also use terms like “grinding it out.” While not ideal, this is the reality of what we must do. I’m going to suggest that we re-frame the compartmentalization.
After compartmentalizing, most of us will numb. Numbing behaviors often involve food, substances, social media scrolling, and binge-watching television. Numbing and soothing are different. Eating a square of chocolate bar can be soothing, but as Brené Brown says, eating the whole bar is numbing. The problem with numbing is that it clouds our memories and prevents us moving through the emotions that will allow us to process what happened.
After two years of the pandemic, on top of 10 years of being an emergency doctor, I hit a roadblock. In March of 2021, I was the most burned out and exhausted I had ever been. I took some time off and started therapy. Initially, most of the therapy was cognitive based therapy. It helped. There were some insights. After a few months, my therapist suggested EMDR. EMDR is eye movement reprocessing desensitization. The main concept of EMDR is that traumas live in not only our mind, but also our body. Rapid eye movements are used to reprocess these traumas and to heal.
With anything involving trauma, it is well known that talking about the traumas can inflict increased emotional distress and symptoms of posttraumatic stress. Thus, in EMDR, one of the first practices they teach is that anytime you start thinking about a trauma and feel distressed, put it in your safe container. The safe container is visualized during an early session. You literally visualize a place in your home that you would keep important documents or possessions. For me, this is a bright blue safe in my office.
How do we put this into practice? Let’s go back to the mom yelling at me related to the mandatory report. As I walk out of the room and I’m rushed into the critical patient, take a microsecond to visualize putting that last interaction in the safe.
Why is this any different than what I used to do after difficult encounters? If something is in a safe, you know where it is, and you can retrieve it later. It is not pushed, stuffed, or numbed away. Rather, it can be retrieved when I have the time, privacy, mental and physical energy to process what happened.
What needs to go in your safe? Well, it varies for all of us. I like Faith Harper’s definition of trauma from her book UnF*ck Your Brain, it’s something that kicked your ass. You are allowed to define what kicked your ass. You are also allowed to acknowledge that different things will kick your ass depending on how much sleep you’ve had, your past traumas, and how much emotional capacity/bandwidth you’ve used up already for the day. Also, stop comparing your traumas to see if it rates going in the safe. For example, “I shouldn’t be so upset by that interaction. I’m thankful to have a job, I mean, it’s not like my life was threatened or I’m working in a war zone.” The comparison game is a defense mechanism to avoid processing traumas.
What do you do with what’s in your safe? That is a question best answered by you and potentially a therapist. For minor traumas, sometimes simply taking it out and thinking about it the next day. You may want to journal or call up a trusted friend or colleague and talk through it. That is often all it takes. For traumas that hit upon another trauma in your life, for example, if the mom yelling at you triggered memories of childhood traumas, that likely requires a therapist to help you work through.
Several times in this article I mentioned that intellectually, I can explain why someone responded the way they did and that it was not truly rooted in a personal attack. We are intelligent and rational people that can reason through all these interactions. More importantly though, we are emotional beings. No amount of rationalization will take away the inherent emotional component to what we do and that it intersects with the story of our own lives. If you’ve been thinking that you can think your way through all of this, I ask you, how’s that working for you? Really? For most of us, we use rationalization as a defense mechanism to prevent us from doing the necessary hard work of processing our difficult emotions. So, the next time you go down the rationalization rabbit hole, pause for a minute, and consider if this would be better to go in the container?
Emergency medicine physicians are expert compartmentalizers. We can go from telling a family their loved one died, to playing peak-a-boo with a child. The only way to move through these interactions with the speed and emotional agility that we need is to compartmentalize. We cannot continue to delude ourselves though, every compartmentalization leaves a residue. It’s like shoving the contents of a vacuum cleaner into an overfilled trash bag, a little cloud of dust floats up and coats us. We often can’t see it, but it’s there and can rub off on the next person. Over years, and years, the nearly imperceptible dust turns into caked layers. It is time we move from compartmentalizing to safely containing and processing.
You don’t have to go at this alone. Reach out today for a free consultation to see how group coaching, masterminds and individual coaching can help you grow and heal.
This blog was originally posted on andreaaustinmd.com