So, I'm Sarah. It's really nice to be here. This is actually my favorite thing to talk about because I think it's really, really important for us to talk about. I have no... Uh-oh, it went backwards again. Can we make it go back to the conflict of interest side? Sorry. If you touch the button either way, they go forward, not backwards. So, I'll try and be more specific with my button pushing. So, I have no conflict of interest, but I do like this topic and I do think it's a very important topic. Okay. Okay. So, for view terms, I'm going to talk just briefly. You just heard a lot about moral injury, so I'm going to talk a little bit about burnout, secondary traumatic stress, and compassion fatigue, which are all sort of on the same spectrum of moral injury. I'm going to talk about some structural barriers that often impact our individual and institutional response to a lot of the challenges that we face. And then I'm going to talk a little bit at the end about some different strategies that we can use to mitigate burnout and moral injury. And my hope is that in the question and answer period, we can use this time to learn from each other and see what works at other people's institutions because I think that's really important that we carry this conversation forward and we share it with each other. So, you just heard from Kimberly about moral injury. Institutional distress, briefly, is when your everyday work violates your personal morals and it also comes from societal and institutional stressors. In pediatrics, our biggest one comes when we would make different decisions than the parents and we have this sort of dichotomy between what we think is right and what they think is right. And I know that happens in the adult world as well. Okay. So, does anyone recognize this? Please don't take a picture of this. Sorry. This is because I was just told yesterday that if we don't have every permission of every single picture, we can't share it. And I realized this morning I don't have every single citation for this particular Buffalo Bills slide. So, please don't take a picture of it. But you guys might recognize this, right? Like this was the Buffalo Bills. This was after Jamara Hamlin collapsed at the game and everybody was super upset. And so, this was really interesting because you saw it in real time. Okay. And so, this is okay because this is cited as USA Today. But Jamara Hamlin's collapse shocked viewers and fellow players. And this is from a head of therapy, kinesiology, at the University of Connecticut. And she says, it's okay not to be okay right now. And it's important to remember that this impacts everybody differently. Some people need to respond acutely and some people aren't going to process it until much, much later on. And I think that's really important. Like, are we at a football game? No. But do we in critical care do CPR every day on young, healthy people? Do we see tragic things every day? We do. So, we do think there's a lot of corollaries between what happened here to what happened in our ICUs. Okay. Perfect. So, this just says, obviously, that there is a connection. And you just heard a lot about that military PTSD, so I'm not going to talk about that as much. But I think it's interesting because it really highlighted what we know and we face every day. So, what are some examples of moral distress at the bedside? I will tell you, working at an institution now that also does complex chronic illness, depending on what state you're in and what state you practice, both adult and pediatric, there are people who are sustained on ventilators with this persistent brain death. And I'm not going to get into brain death, but if you have a state that has a religious objection to brain death, then there are patients that have persistent brain death. But that means people have to take care of them day in and day out. And sometimes it means you have to adjust the fluids and adjust the sodium and adjust the blood pressure. And it is soul-sucking. People do not like it. And when you're working with medical students and residents, and you're like, why am I here today? And you're like, we've got to keep the dead person alive. It really, it's a hard balance for people. And then there's all sorts of connections to your personal life. When you come in and somebody is the same age as your child, there are different things that can trigger moral distress for people. When I think about in the adult world, from an ethics perspective, where we saw our biggest moral distress consult, because that's what we used to call them. There's not anything we as ethicists can do. There's not a decision that needs to be made. But people feel angst and people feel distress. We would call those our moral distress consults. And our number one reason for doing those was because we had patients on ECMO, often young patients who maybe did vaping and were on VV ECMO. And they got to a point where they were no longer eligible for a lung transplant. And they're no longer eligible for a heart transplant, yet they're still on ECMO. They're walking around and awake. God bless all of you in the adult world who everyone's awake and walking on ECMO. But then what do you do? So there's this 27-year-old who's awake and talking to you who is on VV ECMO. He's never going to survive. He can't get a lung transplant. And then everyone's like, well, what do you do? And I certainly don't have the answer as ethicists. We're not going to fix the problem. But I think that's an example of something that's really traumatic for everybody who's caring for them. Both Ram and I practice in Chicago. And some of the things that give us distress at the University of Chicago are that children are shot every single day, every day. And despite children being shot every day, nobody really cares. It's really problematic. So these are just some articles that highlight that it's really problematic. And God bless everybody in Highland Park. You guys probably remember the huge shooting at the 4th of July parade. Well, that was also in Chicago. But it happened to be a bunch of white people who were wealthy were shot. And a GoFundMe for the orphan of Highland Park raised $2 million. Do you know how many orphans there are on the south side of Chicago from victims of gun violence? Countless. Countless. But people are like, okay, has Kamala Harris ever come to Chicago to talk about gun violence on the south side of Chicago? No, she has not. But did everybody rush to Highland Park? And God bless them. Highland Park, you know, the child who was shot ended up at the University of Chicago, which is not a HIPAA violation because it was on the news. But I think it's people don't realize how these are also repeated assault on your morals. Every day you look on the morning news, you're like, oh, okay, there's a newsman in front of Comer. That's what we'll do today. But nobody across the country cares. And in Chicago, just last week, I don't know if you saw the news, there was a shooting the gentleman at the bus stop. But all the people in the media are like, it's okay. It was a gang. And it's like that excuses it. I mean, it's really problematic how disparate the response to gun violence is. Okay, get off my soapbox now, I promise. So what else do we know? And this is something that all of you in the adult world live during COVID. That we in the pediatric world didn't really live until this fall when we had the RSV surge. And then we had a lot of patients that were in community hospitals, couldn't be transferred anywhere. And we said, if you have a new brain tumor, or you have a new leukemia, well, you're a mission critical patient. So you would suddenly go to the top of the list. And you would get priority over the 18 kids on the wait list for an ICU bed that were all three month old babies with RSV bronchiolitis. And I'm sure that happens in the adult world. So we do not triage equally. And we do not triage based on acuity. Sometimes we do. The kid in full arrest, they'll always get the bed. But when acuity is equal, we tend to prioritize based on insurance, diagnoses, who's going to come and do all these different things. So I think those sorts of things also cause a lot of moral distress. And then these were some recent articles from January of 2023 talking about how there's fewer and fewer pediatric ICU beds because it doesn't make any money. Medicaid does not reimburse at the same rates as Medicare. And so everybody's losing money. And so because of this, there's more and more children who have complex chronic illness that can't get cared for because there's not a lot of money in it. And this also is a source of moral distress for people. So what happens? We just heard from Kimberly a little bit about burnout and a lot about moral injury. And compassion fatigue is more when you're at the bedside and you're like, gosh, here we go again. And you don't have tears anymore. And you just feel a little bit numb. And that's how I think of compassion fatigue. You're just numb. And then secondary traumatic stress is on the spectrum of PTSD. And it's more what I think of in terms of the hypervigilance, like you finish a shift, you're driving home, a song comes on the radio, and there's like, you know, a big boom in it. And you know, you have like this whole body shock and your whole body is like amped up on adrenaline. That's how I think about secondary traumatic stress, where maybe you don't feel it during your shift, but you feel it when you go home and different things are triggering for you. And you don't necessarily have all the DSM-IV criteria that you would for PTSD. But secondary traumatic stress is a real phenomenon. So burnout. What do we know? We know the rates are really, really high. We know that it's worse now than it was before. It is defined as these three things, overwhelming feeling of exhaustion, cynicism and detachment, and this sense of ineffectiveness. You know, this sense that I finished my shift and nothing was really different at the end. And I think that's the type of mindset that leads us down this road of burnout. So this happened just this week. I must say burnout, it's like the gift that keeps on giving. You cannot go seven days without something related to burnout in the news. So everybody might not recognize this, but her name is Jacinda Arden. She was the prime minister of New Zealand. In terms of women in the world and women leaders, she was like amazing, right? Like she had a newborn baby, she went into office, she was breastfeeding in parliament. Like everyone idolized her, both her response to semi-assault weapons, her response to the volcano, her response to the pandemic. Many people said she's one of the most effective leaders in the world. She got it done. Her daughter is now four years old. And what did she say? She says, it's in here somewhere. She said, I am human, politicians are human. We give all that we can for as long as we can. And then it's time. And for me, it's time. And so four years, she was an amazing leader. And she's like, peace out, not going to do it anymore. And she doesn't deny why. She says, it's burnout. If I cannot give it my all, I'm out. So what about our fellows? This was an article that was published in June of 2020. I'm sure it's even worse now, but this was looking at pediatric critical care medicine fellows in the United States. And we knew that there were high levels of burnout, that there's emotional exhaustion was higher among women. Those who maybe had mixed feelings about their choice to pursue fellowship had much higher levels of burnout. And then those who perceived burnout around them, which I also think you have to think about how do your actions and words impact everyone around you. And when you're the burnt out attending, that filters down, right? Your medical students see it, your residents see it, your fellows see it. You're like, oh, another one, I can't take it anymore. That filters down to everybody else who's working with you. And this was a study, this, the, oh shoot, can we go back two more? Sorry. The critical care fellow study was done surveying fellowship directors across the country and there was a 70% response rate. So that was all. I just wanted to tell you that. This is a study that I did collaborating with Brig Willis, who's at Arizona. It's a little bit older now, but we looked at pediatric ICU attendings and burnout. And we found the prevalence of secondary traumatic stress was 50.9% and the overall rate of burnout was 45.8%. And this was of the people who responded to our survey. And those who had been in practice for 10 to 15 years had much higher rates of secondary traumatic stress, which is that sort of hypervigilant stage that I was talking about. There was no specific demographic that we found, but we did find high levels of emotional exhaustion and burnout. Okay, so suicide. So when people say, what is the impact of moral distress, moral injury, all these things at the bedside, the worst case scenario is suicide. And this is a really, really hard topic, right? Because people don't like to talk about it and they don't like to acknowledge it. I can tell you off the record that at the University of Chicago, in the children's hospital alone, not the adult hospital, in the children's hospital alone, there have been three suicides in the last two years. And is this a news story? No, it's not because people don't want to share and people don't want to talk about it. But you know, because people are friends with the people and friends with the family, but there's so much shame and so much stigma. So what happens when a physician kills themself? Everyone says, oh, they had problems all along or, well, they could never cope anyway. People don't stand up and say, this is really bad. We should do something about it, but nobody is. And Lorna Brain, oh gosh, can we go back to my Lorna Brain slide? I'm sorry. I think we had to, off topic, we had to pre-record for in case we weren't here. And so I think the animation is built in. And so it keeps going. But on the picture on the slide before this, there was a picture of Lorna Brain. So Lorna Brain was an ER attending at, thank you, Columbia University. She died of suicide and her sister and her family set up a foundation to talk about this and do this and really sort of study why we have such high rates of suicide among physicians. And then they're also looking at whether or not COVID impacted her brain. Did she have some sort of post COVID encephalopathy? And I think that's also really common because people want to find an excuse for why someone committed suicide. And people don't ever want to say it was the system. It was what we do every day. And I think at some point, we have to get past the shame and the stigma while respecting the privacy of all of the families because that's why you don't see the stories in the news because the families don't want to share that. And of all the families at our institution, all of them had school-aged kids. And no, their kids don't want to open up the Chicago Tribune and read again about what happened because that's further traumatizing those children. So I don't think sharing their names is obviously not the answer, but how can we talk about it and validate that experience without saying, oh, they were a one-off, oh, they always had problems. Because you know, you know that's what people do. Okay, and this was just a more recent article talking about this sort of increased risk of physician suicide. This is a more recent article from 2022. And I just liked the last quote of this, which is that there exists a rare opportunity to raise awareness of, advocate for, and implement policies that promote physicians' occupational and mental health. And doing so may be the best medicine to reduce this problem. So it is a really, really big problem. And it's something at some point we have to address. So what should we do? I love the name of this talk, like our overall session, which I had nothing to do with, but it said overall, don't just stand there. You have to do something. To me, the biggest problem lies into the shame and the silence, the fact that we don't talk about it. And then when something bad happens, we don't process it and we don't put systems in place with it. So is talking the answer? People sometimes used to make fun of me just a little bit when we were doing our ethics consult at our moral distress, because we would go and we would set up these multidisciplinary meetings with myself and one of the nurse managers and one of the nurse coordinators of the ethics teams and the chaplain, and we would say, let's just sit and talk about it. And we would do it a lot in the surgical ICU where they had these adult patients on ECMO and things like that. And we were like, let's just talk about it. Let's give it a safe space. Like there has to be a safe place for you to talk about. And so I do think debriefings are really, really important. It's not something that's always embraced. It's not something that's always encouraged. And it's interesting, because I've gone back and back forth with our head of psychiatry who oversees our compassion fatigue for the institution. And what he has said is that there is data from the, we have to go back like four more slides, I think, sorry, that there is data from the psychiatry world that if you're in a break room and in the break room, you're saying, this is a horrible day, this is a horrible day, and nobody's facilitating it, that can make compassion fatigue worse. But if you're in a structured environment with chaplains and with facilitators and with trained people, then there can be a lot of value to sharing your feelings. So I think we have to figure out how we can do it. And it's interesting, right? Because almost all the institutions that do CPR have an immediate post-code debriefing where you fill out a little checklist. Did your defibrillator work? Was it charged? Did the pads connect? But we don't have an emotional debriefing. And at our institution, I always try to separate them. I'm like, yes, it is really important to talk about the technique of the code. Did you have a code leader? But you also have to talk about how it felt to those people doing CPR and doing all those things when there was a bad outcome. So how do you balance those things out? So we actually did a study looking at our pharmacist as well, because a lot of times, these debriefings are done in silos. Doctors talk to doctors, nurses talk to nurses, physical therapists talk to physical therapists. How can we get everybody all together? And so we looked at burnout among pediatric pharmacists in our institution, and we found that 73% were really distracted after a code, and that 87% felt burnt out at work. And then 40% of them, which is the pediatric pharmacists, felt as though there would be a benefit to talking about their feelings and having a safe environment for debriefing. We still have to go back two more slides. There we go, okay. So is resilience the answer? You heard from Kimberly about all the different people who are no longer doing, no longer practicing medicine, and this happens all the time. I will tell you, I have like a love-hate relationship. You know, in 2015, I think, I left and I went for the insurance world for two years. Turns out that didn't make me any happier, and I belong in an ICU, so I came back. But I think people do it. When I think of people, my fellow classmates, they've gone to work at drug companies, they've gone to full-time research jobs, people have gone to insurance, people have gone to administration. There's so many different places that people go because they don't necessarily want to stay in critical care. And I think we have to think about who are the people who are our mentors who are still doing it. You look at the sort of upper echelons of Society of Critical Care Medicine, and it's all men for the most part, with the exception of Sapna, God bless her. But I think there are differences when you look at who really can do this long-term, and you look for women role models who have done this long-term, and there are not very many. You can count them on probably less than one hand. So this, I thought, was a great quote, because I do think one of the lasting gifts of the COVID pandemic was to stop this sort of self-sacrifice. Like, your life doesn't matter. I don't care if you have a fever. Put a mask on and come to work. And I think this was a nice paper that was written that says one of the things that came out is we don't want to ask them to sacrifice their well-being on a routine basis. And I think that's really important. And so here, what are some of the things we can do institutionally? Like I said, I think everyone and their cousin should get an ethics consult, and have a meeting, and eat donuts, and talk about all of your feelings. But there's different ways, right? There's Schwartz Center rounds, there's palliative care consultations, and then there's spiritual care teams. And I think after one of the most recent suicides in the hospital, there were a lot of emails out reminding people you can call employee assistant, but you can also call your local chaplain, and your chaplain is happy to talk to you about staff support. But prior to this most recent suicide, did anyone ever talk to the chaplains about staff support? I can tell you they didn't, because we shared an office with him, and nobody ever did. Like, we would bring them to a conference, but otherwise, that wasn't something people were doing. So I think we have to look at how we can look at what our current infrastructure is, and how we can tie that in to staff support. I do think that it's really important that we recognize this. Within our graduate medical education office, we're doing a lot of opt-in therapy appointments. So instead of saying, here's the number, call in a crisis, and press the number nine, we're saying, hey, we made an appointment for you, a once a month therapy appointment for every resident, we're gonna have you go. And some people are doing that with faculty, and we reward the people who see the most patients and work the hardest. But maybe we should reward the people who take care of themselves. Maybe we should reward the people who maximize their vacation. I mean, there's no reward at the end if you haven't used any of your vacation. I'm like notorious for not ever taking vacation. I was like literally jumping up and down, literally, in front of the sand yesterday, because I was like, this is my first time away from my kids in five years. Like, it's super exciting. But I think we have to think about how do we have time away? And how do we celebrate that time away is important? So I'm gonna go through a couple different papers that were written in Peds Critical Care Medicine. Peds Critical Care has a narrative section, which I think has been really beautiful and a really great way for people to share. And so this was an article that was published in June of 2021. And they said, not only are we human, but we have to learn to preserve. And heal our own hearts on this difficult career journey. And then it's okay to forget. People remember the feelings, but it's okay if you don't remember every single person's name. But it's also okay to remember. I think sometimes we think, okay, shift over, not there anymore. You know, it's like a whiteboard. Clean off your head, go home, move on to the next one. But I think, I thought these were all different articles that were helpful. Whatever you do, it's okay. You might be someone who remembers, you might be someone who forgets. They're both fine. It's all however you wanna do it. And I think this was just a good slide that for each person, the same case might be different. You know, for somebody, it might be a ray of sunshine. For somebody else, it might be a really bad storm. And I think for all of us, there's this juxtaposition of dealing with critical care people at work, and then going home and talking to your healthy spouse, or your healthy family, or your healthy whatever. And it's a really weird juxtaposition. And I remember when I was doing a withdrawal of support on a little baby, and the family didn't wanna be in the room, so they were in the hallway pacing, and I'm like holding this baby. She's literally dying in my arms. And I was seven months pregnant. And so, granted, this was a long time ago. But the fetus, my personal, now 15-year-old, kept like kicking, you know, kicking. And you could tell as I'm like holding this dying baby, and then she would go like this. And the family's like, is she alive? I'm like, no, no, no, I'm sorry, I'm sorry. But like, it's weird, right? There's this juxtaposition of life and death, and you see it all the time. And how do you balance those things? And how do you acknowledge how weird it is to be like holding a dying baby while your own fetus is like kicking that dying baby? Because you can't control them. Although, I must say, now that I have teenagers, you still can't control them. It's not any better. Kind of a nightmare, which is this other reason why I was so happy to be away from my children. And this is an amazing article. Maya Duen from Cincinnati wrote this article. She has several children. And she talks about how she cannot let go. And she shares a story when her, she's in the room, people are withdrawing support for someone who's the same age as her child, listening to the same music and the same video that her baby loves. And at the same time, her little Apple Watch is blowing up because her babysitter sent pictures of her child outside building like snowmen or something. And I think, again, it's that juxtaposition of life and death. And she talks about how it's okay to cry in the moment. And I just think it's a really, really insightful article. And I think it's just important to read and just to know that it's important to acknowledge these things. So wellness. What are the answers? I have no idea. But I think that's something that we should all try and talk about together. I do think people have to be really mindful of mental health. They have to be really mindful of knowing what brings them joy. I trained at University of California, San Francisco a very long time ago, in the 90s. And I know that the Golden Gate Bridge brings me joy. I just love that bridge. I've lived it my whole life. So yesterday, when one of my friends was like, what can we do? I'm like, I want to drive over the bridge. But like, we just need to know what are the things that bring us joy. Because there might not be very much. Sometimes it might be Ben and Jerry's. Like, you just need to know what is it that you can find that you can self-soothe, just like babies do. What can you do to bring yourself some joy? I do think it's important for all of us to become an activist in all these different things that are really problematic in our world. And I think it's really important to have a sense of the change that we can impact. And this is a starfish story where it's an old parable where someone's, you know, walking along the beach, throwing in the starfish. And the old man says to the little boy who's throwing them all in, what are you doing? There's thousands of starfish. You will never make a difference. And he says, but I made a difference to that one. Sorry, I'm so like emotive. That's the other way I've been doing this for so long, is I'm very emotive because I do believe we should like share our emotions. I think it's really important what we do. I think we have hard jobs. I think we need to give ourselves grace and compassion. And I think one of the things that we talked about recently was how you have to have personal mentors. You can't necessarily go to your boss for every little thing because at some point then they can't always be supportive of you because they're the same person who's saying to you, well, you need to publish three papers and raise your RVUs and do all these different things. And I think I've been really fortunate to have mentors in ethics and mentors in different parts of the world where I could connect with people. And Raj Basu, who is one of the pediatric intensivists who's running the program at Lurie, he created a program called the Guardians. And what's beautiful about the Guardians is it's a mentorship program matched on like personal interests. So I've been matched with a doctor from Emory and matched from a doctor from Seattle who are both young women. And it just gives us an opportunity to support one another and collaborate. And if you really want to talk to somebody, you can't necessarily always talk to your boss. So I think having these personal mentors and knowing who is your mental health mentor, a lot of people we say, who's your research mentor? Who's your clinical mentor? Well, who's your personal mentor? Who is your person you're going to call in a crisis? And you need to think about that as well. But I think overall, I think it's really important that we talk about this. And I think it's really important that we feel the feels. And I'm super guilty. I give everybody hugs, but I do ask permission before I give hugs. But that's all. So hopefully we can have discussion about what people are doing successfully at their institutions and how we can help each other.

burnout

compassion fatigue

safe space

moral distress

mental health

self-care