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Episode 11 - Palliative care in the trauma bay - Red Hoffman, MD, ND, FACS
26 Plays1 month ago
Dr. Hoffman is a trauma surgeon in Asheville North Carolina, a hospice medical director, and a founding member of the Surgical Palliative Care Society. We discuss her unique path into the palliative care field and how she uses her skills in the trauma bay and the ICU to help her patients both survive devastating conditions as well helping patients and families transition through events which may be non-survivable, as well as conditions with outcomes which patients would ultimately find unacceptable if aggressive medical interventions were to be pursued. This interview was recorded in October 2023 and previously released.
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Transcript
Introduction and Guest Introduction
00:00:00
Speaker
This is the Pallium Podcast, a production of pallium.org at the intersection of palliative and emergency medicine.
00:00:07
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I'm your host, Justin Bruton.
00:00:10
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Today on the Pallium Podcast, I'm joined by Dr. Red Hoffman.
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Dr. Hoffman is a trauma surgeon and associate medical director of both hospice and palliative medicine in Asheville, North Carolina.
00:00:21
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She is one of approximately 90 US surgeons currently board certified in hospice and palliative medicine and is a clinical assistant professor of surgery at the University of North Carolina School of Medicine.
Dr. Hoffman's Work and Influence in Palliative Care
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She speaks and writes nationally and internationally about the intersection of surgery and palliative care and her work has been featured in JAMA, Doximity, KevinMD and General Surgery News.
00:00:41
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Red is the founder and host of the Surgical Palliative Care podcast and is the co-founder of the Surgical Palliative Care Society.
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She is currently launching a new podcast called The Surgical Soul and is writing a memoir.
00:00:55
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Dr. Hoffman, thank you so much for joining me today.
00:00:58
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Oh, thanks for having me.
00:00:59
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You can call me Red, by the way.
Impact of Palliative Care in Surgery
00:01:02
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I'm so glad we could finally meet to record.
00:01:06
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I had had a chance to interview Buddy in the past, and I really liked what he had done with our surgical team and teach them more about palliative care.
00:01:14
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And also just the surgical palliative care society.
00:01:17
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I know that I'd seen a lot of press about the society, so I think it's doing a great job of really highlighting the need for palliative care in the surgical world.
00:01:25
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So one thing I'm really curious about is tell me a little bit more about how you entered this world of surgery and palliative care, because that's such a unique combination.
00:01:34
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Sure.
00:01:34
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So I actually had a very windy road to get to where I am.
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I actually started my life, my professional life as a naturopathic doctor and a yoga teacher.
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And in the midst of my naturopathic training, went to India.
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Um,
00:01:49
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to study homeopathy actually.
00:01:51
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And that was the first time I was in the OR and I fell in love with surgery.
Career Path and Influences
00:01:54
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And so when I got back to the States, I said, oh, I think I made a mistake.
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I want to be a surgeon.
00:01:58
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And when I, I was very lucky to go to medical school at OHSU in Portland, Oregon,
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where I was already living.
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And for those of you who don't know, Oregon is the birthplace of death with dignity and OHSU where I went to medical school was the birthplace of the post form.
00:02:16
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So where we practice Justin in North Carolina, it's called the most form, but it's different forms all over the country.
00:02:22
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Um,
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And so, you know, palliative medicine like was just embedded into my medical training.
00:02:29
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And in my fourth year of medical school, even though I already knew I wanted to be a surgeon in my fourth year of medical school, I did one month with the palliative care team.
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And it really it just like changed my life.
00:02:41
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And I ended up going to residency in Arizona at the county hospital in Phoenix, and we did not have a palliative care team.
00:02:48
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And I saw an inordinate amount of suffering.
00:02:51
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I mean, so much suffering.
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And I spent a lot of time in the ICU.
00:02:57
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I always kind of found my way back there.
00:02:58
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And then also we had a huge burn center, which I always found my way back to.
00:03:02
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And there are a lot of suffering in the burn center as well.
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And
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I ended up doing a lot of primary palliative care, just the stuff I learned as a fourth-year medical student because no one was doing much else, I have to say.
00:03:14
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But eventually, I started thinking about it.
00:03:16
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I really was very interested in trauma surgery.
00:03:18
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My father was murdered when I was 19 years old, so that definitely led me into...
00:03:22
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the trauma world, and also probably like the hospice and palliative medicine world.
00:03:28
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And at some point I started thinking, how the hell am I going to combine these two worlds?
00:03:32
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And, you know, thanks to the magic of the internet, I ended up finding Ann Mosenthal, who I call her the mother of surgical palliative care, and Jeff Dunn, the father of surgical palliative care.
00:03:44
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I found them both on the internet.
00:03:46
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And there was really one...
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like book that we all used at the time.
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And it was put out by the American College of Surgeons.
00:03:54
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And it was called, I think, a surgical residence guide.
Career Path Shift: Naturopathic to Surgical Medicine
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And it was all about surgical palliative care.
00:03:59
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And that's really helped me start to shape what my life might look like.
00:04:05
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Wow, that is a and I thought I had a winding path.
00:04:08
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You had a really winding path.
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And I can't imagine going from like naturopathic, homeopathic principles to like being in the operating room.
00:04:19
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I mean, that is, I don't know of a more stark contrast.
00:04:21
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So actually palliative care and surgery were actually not much of a, not really much of a leap at that point because you'd already taken a really big leap to begin with.
Education Path: Fellowship vs Short Courses
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Right.
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Yeah.
00:04:33
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What was, you know, it sounds like it was really out of necessity.
00:04:37
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And the other thing you mentioned that I think I've just encountered often is that people who gravitate towards palliative care have had to deal with some kind of loss and they've had to deal with something really profoundly impacting them.
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And I think that that's almost, it's almost necessary in a way to be able to emphasize with kind of the pain that some of our patients and their families go through.
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And I think it's just a unique trial by fire that I feel like many of us have had in a different way.
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That prepares us for that.
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Do you feel like you've I'm just curious knowing going from the side, I feel like I definitely kind of people like, oh, that's unusual, you know, combining the two of these.
00:05:13
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And it seems like you were able to just it was just part of being a surgeon and just a normal part of what you did when you were training because there wasn't other consultants there to help.
00:05:22
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You just had to develop those skills yourself.
00:05:24
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Have you ever kind of come across scenarios where you had, you know, other surgeons who really kind of didn't understand the context of palliative care or you kind of felt like you were swimming upstream?
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Just curious.
00:05:35
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Sure.
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I think in the beginning, people couldn't wrap their heads around it.
00:05:40
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I will say, you know, my field of surgery, acute care surgery, which is that mix of trauma, emergency general surgery and surgical critical care, it lends itself so well to hospice and palliative medicine when you think of what we do.
00:05:53
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And I think there's
00:05:55
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other fields of surgery that may lend themselves more towards that as well.
00:06:02
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So what I found for me was there were certainly people in, say, when I was training who were really questioning, what is this going to look like?
00:06:10
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And that was, for me, one of the reasons why I wanted to do a fellowship.
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I always tell people, I mean, the vast majority of us, whether we're in EM or surgery or
00:06:21
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any field, we're not going to do a hospice and palliative medicine fellowship.
00:06:24
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And that's fine because there's not enough hospice and palliative medicine doctors and we all need to be practicing primary palliative care.
Integrating Palliative Care into Surgery
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But for me, I felt like the fellowship, I really did it at the beginning because I felt like it was going to lend a lot of legitimacy to my career path.
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what I found once I did it was I thought I really knew a lot and I just realized I just knew the tip of the iceberg.
00:06:46
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And I just, it was really one of the more like profound years of my life because it really allowed me to slow down, right?
00:06:53
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Cause the pace is so different than, than the rest of our training, whether it's EM or surgery.
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And it just really showed me, Oh God, how much I didn't know about communication and just taught me, taught me so much.
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And now I'm,
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So even so one of the things that I was very blessed is like I did my palliative medicine training, my fellowship where I ended up practicing surgery.
00:07:17
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And that has led to like such a beautiful career for me.
00:07:20
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But at the beginning, when I like started my surgical attending career, I'd like come to the ICU and the nurses would be so confused because they knew me as a palliative care fellow for a year.
00:07:30
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So.
00:07:30
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So they'd always ask, like, are you wearing your, they used to ask, are you wearing your palliative care hat or your surgical hat?
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And I'm like, uh-uh, that's not how I think.
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I am like one being offering the full spectrum of care.
00:07:41
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And of course, now, years later, no one's offering me that.
00:07:45
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And I always joke, like, you know, if I can't save your life, then I am going to try as hard as I can to give you and your family a really good experience around death and dying.
00:07:56
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That is so awesome.
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And it's so interesting.
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I can relate from the standpoint of somebody who really likes critical care.
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One of the things I'm curious about is what you would say.
00:08:07
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So what you would say to somebody where you really benefited from fellowship, you think it's really shaped your career, taught you a lot of things that you wouldn't have known otherwise by kind of that challenge.
00:08:19
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What would you say to the person who's kind of on the fence between like, do I want to just maybe do like a short course and maybe learn a little bit more?
00:08:26
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Or am I really thinking about a fellowship?
00:08:28
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I feel like I could try to answer that question, but I want from your perspective, like what you think makes the distinction between somebody who should consider a fellowship versus maybe a short course or some additional resources.
00:08:39
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So I think it's important to think about what do I want my life to look like?
00:08:43
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Now, I, well, I could never have imagined what my life has ended up looking like today.
00:08:49
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But I will tell you, because now I only work part-time surgery because I ended up with a chronic illness, having this fellowship was great because it really allowed me to shift and really make the case to have all this administrative time to do all these
Strategic Career Planning in Surgery and Palliative Care
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things.
00:09:05
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So I do ask someone like if their one true love is the OR, like let's say I think of my friend who's like a CT surgeon and like they just want to be in the OR all the time.
00:09:15
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I don't think having a year long fellowship is going to add a lot to them.
00:09:19
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I really don't.
00:09:20
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But then I think of like my friends or colleagues who are very interested in that world of acute care surgery where you're spending at least a third of your time usually in the ICU.
00:09:31
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I mean, it lends itself so well to the ICU.
00:09:34
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And again, I have great colleagues who are not fellowship trained who work in the ICU too.
00:09:40
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But like to me, that's where I might actually say it's going to really work out well for you.
00:09:45
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And then the other people who like may have spent some time in hospice at some point in their life and they know they want to go do that.
00:09:51
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Now you can certainly get a hospice job.
00:09:53
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I mean, hospice jobs will hire you without a hospice and palliative medicine fellowship.
00:09:58
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But if it's something you're really interested in, like you could see yourself doing a part-time surgery and part-time something else, then I think it's another great, a great idea.
00:10:08
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And I say too, like I was older.
00:10:11
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I mean, I, I finished my training when I was 44 and
00:10:15
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I've always known like I'm going to need an exit ramp.
00:10:17
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Like I just knew it, you know.
00:10:20
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And so that was also like part of my planning in advance was like, I'm going to need an exit ramp that I know is going to be there.
00:10:27
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And so I knew that I could end up being a hospice medical director at some point and be very happy.
Founding the Surgical Palliative Care Society
00:10:34
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So I think it's all about what you want.
00:10:35
Speaker
And then also like how much debt you have, how young or how old you are, you know, is that an extra year of training is, you know, more, more loans that you're not really repaying and, you know, a whole year of salary that you're not making a 401k that you're not getting.
00:10:53
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So you have to think about it.
00:10:56
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Well, the other thing, too, I feel like is you have it gives you the skill set to educate others, I think, as opposed to let me just get some skills for myself.
00:11:04
Speaker
So I feel like you're doing, you know, and I was like, that's going to segue to my next question about the Surgical Palliative Care Society.
00:11:10
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But you're doing that working with the Surgical Palliative Care Society.
00:11:14
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You're kind of disseminating some information about the field.
00:11:17
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So having that fellowship training, I think, is really is probably really helpful for that role.
00:11:22
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Although again, I will say, I always think of my friend and colleague, Mackenzie Cook at OHSU, who is like, I just think such a leader in the field of surgical palliative care.
00:11:33
Speaker
And he did not do a fellowship.
00:11:34
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And he's also an excellent surgical educator.
00:11:36
Speaker
So it's like there are people out there.
00:11:39
Speaker
But then I think, you know, the benefit of Dr. Cook is like, he trained at OHSU.
00:11:45
Speaker
So like the whole surgical department is steeped in palliative care.
00:11:48
Speaker
And then he did a fellowship at OHSU.
00:11:50
Speaker
UW and like so many leaders in the field of surgical palliative care and palliative care in general came out of UW.
00:11:59
Speaker
So it like it really depends on like what your base of training was, too.
00:12:02
Speaker
I mean, from where I was sitting, like I said, I didn't even have I didn't even have a palliative care team where I did residency.
00:12:08
Speaker
I really needed to do a fellowship.
00:12:11
Speaker
No, that makes a lot of sense.
00:12:12
Speaker
And I definitely see that we are palliative care team gets we have residents or we get medicine residents that rotate through our service routinely.
00:12:20
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And then when I work with the residents, I get a mix.
00:12:23
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Some of them are like, I have never seen this before, you know, and others, others, you know, went here and they already know me.
00:12:29
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They knew me as a medical student.
00:12:31
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And so you're right.
00:12:33
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There's still a very.
00:12:35
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very wide ranging experience that people are going to get in training right now.
00:12:39
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Hopefully at some point it will be more homogenous in the sense that there's going to be more exposure to that routinely across the board, but it's definitely, and the EM is definitely not the case yet.
00:12:47
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And I'm sorry to interrupt, but I hope like for my, I think my residents by the time they're done are going to be so great at palliative care.
00:12:55
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Like we, we've only graduated two years of residence so far, but like, I think they're just going to be incredible.
00:13:02
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I'm curious to hear a little bit more about the development of this Surgical Palliative Care Society, kind of your role with that right now and what you're accomplishing through that organization.
00:13:13
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Sure.
00:13:14
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So the idea for that was born in...
00:13:19
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October of 2019, myself and my two co-founders, Dr. Buddy Martier and Dr. Pringle Miller, were at a very small dinner on the last night of the annual clinical congress in the American College of Surgeons.
00:13:34
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And we're going to be here.
00:13:36
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just started talking with a group of people and, and it was actually born, born through that.
00:13:42
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And, um, it took about two years to, it was a very long gestation period and, and a lot of learning.
00:13:49
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I mean, we started this whole organization by herself with no help.
00:13:53
Speaker
And, um,
00:13:54
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Pringle had actually started another organization.
00:13:56
Speaker
So she had a little background, but we, it was such an experience to like hire a management company and get a 501 3C and learn how to fundraise and build a website and, um, and then be born.
00:14:10
Speaker
And we did have a lot of support at the beginning from general surgery news and from the American college of surgeons.
00:14:15
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And why I had a podcast at the time.
00:14:17
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So we just got a lot of a great press.
00:14:19
Speaker
So we had our first, um, uh,
00:14:24
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conference last year and our second conference coming up this year.
00:14:29
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And it's been really interesting.
00:14:31
Speaker
You know, we tried to build the organization.
00:14:35
Speaker
One buddy really, you know, Dr. Martir, he is a beekeeper and he is very interested in how the hive works and it's really a community.
00:14:43
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And he really wanted to build this organization based on
00:14:48
Speaker
on how the hive works.
00:14:50
Speaker
And really also, you know, when you think of how, uh, how a well-functioning palliative care team works, right?
00:14:55
Speaker
It's this interdisciplinary team where so different than say surgery, where the surgeon it's a team, but the surgeon in the end of is the captain of the ship.
00:15:04
Speaker
Like I'm palliative care.
00:15:05
Speaker
I remember being so touched in my fellowship.
00:15:07
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There is no captain of this ship.
00:15:09
Speaker
The physician is just as important as the chaplain.
00:15:12
Speaker
Who's just as important as the social worker, who, if you have a pharmacist is just as important as the pharmacist.
00:15:17
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And,
00:15:18
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So I really tried to build it like that, which, right, like brings up its own, um,
00:15:23
Speaker
It's very beautiful and then can be really challenging because then in the end, you're like really making decisions as a team, which can take a long time, you know?
00:15:32
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So it's just been a very interesting experience.
00:15:36
Speaker
And, you know, the purpose of the whole organization was one to obviously educate the surgical community and then to build fellowship and, you
00:15:51
Speaker
Two was to just kind of nurture that next generation of surgeons who are coming up who are going to be the next leaders in the field of surgical palliative care.
00:16:00
Speaker
Because like I said, when I was interested, it was like one little book on the internet.
00:16:04
Speaker
And now we want it to just be so easy to find us so that anyone who's interested can reach out and kind of start planning their career.
00:16:12
Speaker
And what is that going to look like for
Intersecting Trauma and Palliative Care
00:16:14
Speaker
them?
00:16:14
Speaker
In this press that I've seen about the Surgical Powered of Care Society, it sounds like there's really been a lot of uptake of that.
00:16:19
Speaker
So that's exciting.
00:16:21
Speaker
I feel like that's going to be impactful.
00:16:23
Speaker
Like you mentioned, you trained somewhere that that was just part of what you did and it was part of your experience, but everybody has that.
00:16:30
Speaker
So I think this has a chance to really let a lot of other future surgeons or surgeons in training know what's out there.
00:16:37
Speaker
Speaking of that and thinking about your experience as a trauma surgeon and also thinking about the people that
00:16:43
Speaker
that listen to this that are working in the ED or working in palliative care.
00:16:47
Speaker
I'd really love to know some of your pearls that you've learned about dealing with the patient and the trauma bay.
00:16:53
Speaker
Sure.
00:16:54
Speaker
So when I think of, you know, say...
Patient Care Approach in Trauma Settings
00:16:58
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how trauma intersects with palliative care, I really think of four different things.
00:17:03
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I think about care of the patient, care of the family, care of the team, and care of the self.
00:17:10
Speaker
And I can kind of go through each of those a little bit.
00:17:13
Speaker
But, you know, when we think about care of the family, I mean...
00:17:17
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or I'm sorry, care of the patient, you know, right up front, obviously, if it's a trauma patient and they're actively dying, you have to do what you have to do.
00:17:26
Speaker
And so I often say about trauma and about ICU, I mean, we cause a lot of pain for our patients, but if the end result is going to be worth it, which is to me, a life worth living, whatever that means to an individual patient, then, you know, that pain is sometimes part of the picture.
00:17:44
Speaker
But I think, um,
00:17:46
Speaker
with our trauma patients, it becomes clear often rather quickly whether this is going to be a resuscitation that's not going to go well or it just doesn't go well.
00:17:55
Speaker
You know, we try to resuscitate them or do a resuscitative thoracotomy and it just doesn't go well.
00:18:01
Speaker
Or say in the case of a head injury, we get the patient to the CT scanner, they come back and it's just what would be considered a devastating brain injury with like impending herniation.
00:18:12
Speaker
Then I think that flip starts to, um,
00:18:16
Speaker
that switch starts to flip for me a little bit.
00:18:18
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And then I'm like, okay, I can move more into this approach, maybe, um, based on comfort and totally on symptom management.
00:18:27
Speaker
And so I do a couple of things there because one, um,
00:18:32
Speaker
Even some of our trauma nurses are not always comfortable with the amount and the different medications that it takes to really comfort someone in their dying process.
00:18:44
Speaker
So I do a lot of education with them.
00:18:47
Speaker
I think it's really important if you're writing orders, you know, everyone has like their order sets that we have this palliative care order set for the imminently dying that we use.
00:18:57
Speaker
I think it's really important to talk to the nurses since they're the ones administering the meds to make sure that they're comfortable giving an opioid, a benzo, and sometimes an antipsychotic all at the same time at the doses that I'm asking them to give.
00:19:14
Speaker
So one, if they're not comfortable, then I try to find another nurse to help them.
00:19:19
Speaker
Or two, if I have time, I really like to spend time in the trauma bay when the patients are dying.
00:19:24
Speaker
because like to me, that's another part of my job that I think is a really precious time that I like to be a part of.
00:19:33
Speaker
And then two, I'm a real big fan and I'm actually just rewriting the order sets right now, especially for our new nurses.
00:19:39
Speaker
We have so many new grads who are just shoved into these like really intense positions to give them really objective data to use.
00:19:47
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So I'm like, all right, I just tell them, listen, if the heart rate's greater than 100,
00:19:52
Speaker
knowing full well that some of that might be due to hemorrhagic shock, but I just use that.
00:19:56
Speaker
Heart rate greater than 100 or respirations greater than 16 or any non-verbal indications of pain, whether they're grimacing or grunting or just kind of reaching out and
00:20:09
Speaker
being really agitated, like this is when we're going to treat.
00:20:12
Speaker
So I try to kind of help guide them because it's hard.
00:20:15
Speaker
You know, they're used to using these pain scales that are like one to 10 and you can't always ask someone that.
00:20:20
Speaker
So those are kind of the things that I try to do to help take care of the patients.
00:20:27
Speaker
So one of the things you mentioned that I think is really interesting is you'll kind of notice as you're in the process of a resuscitation or you're thinking about the kind of injuries the patient has, sort of seeing that signal that we may need to transition from resuscitative care to comfort measures.
00:20:42
Speaker
And sometimes that line is very apparent, devastating head injury or non-survivable, penetrating trauma, et cetera.
00:20:50
Speaker
But
00:20:51
Speaker
There's times where I've had patients where they may have a survivable issue, but the outcome, at least for the patient, would probably lead to something unacceptable.
00:21:00
Speaker
I'm just curious if you've encountered the same thing and how you approach that, because sometimes we can see something that we think is going to be an unacceptable outcome for the patient, but if they're still going to survive potentially, that still is a very foreign concept of transitioning care, even when survival is possible, but under very specific circumstances.
00:21:18
Speaker
I'm just curious.
00:21:20
Speaker
Like my care, my personal care of patients in the actual trauma bay, downstairs in the ED, I think if I see someone who I know is going to have, like, say that devastating head injury, that's an easy, that's a bit of an easier call.
00:21:36
Speaker
I think what I found with situations like that is one loading the boat, like bringing the neurosurgeon with me so they can hear from, from two specialists that like, this is likely going to be an awful, awful outcome.
00:21:49
Speaker
I'm a real, I talk a lot about this idea of decisional burden and my desire to relieve families of decisional burden.
00:21:57
Speaker
That's about care of the family.
00:21:58
Speaker
I have to remember, as I'm a survivor of two different violent losses, and I know how...
00:22:05
Speaker
The way those losses kind of play out can affect someone the rest of their lives.
00:22:11
Speaker
And so I never, you know, I'm not offering any further resuscitation in a lot of these.
00:22:16
Speaker
I don't ask, do you want?
00:22:17
Speaker
I'm like, I just want to be clear.
00:22:19
Speaker
If their heart stops in this situation, I'm just going to allow a natural death.
00:22:24
Speaker
And I think it's important to say that maybe 50 years ago it wasn't, but now everyone watches TV and is on the internet all the time.
00:22:30
Speaker
So you want people to know, I was thoughtful about this, but this is not an option.
00:22:35
Speaker
You know, it's going to be futile, basically.
00:22:41
Speaker
So I think those situations are kind of actually almost a little more straightforward.
00:22:45
Speaker
Those cases that you're talking about where the likelihood of life is not going to be great.
00:22:52
Speaker
I mean, I've actually learned over time.
Decision Making and Family Support in Palliative Care
00:22:55
Speaker
I'll say when I during my hospice and palliative medicine fellowship and probably my first two years of practice, I kind of leaned a little more towards death and dying.
00:23:06
Speaker
And over time, I've kind of come back to the middle.
00:23:08
Speaker
And I've learned that, you know, sometimes we just need to wait 72 hours to sort some shit out, to be honest with you, and kind of like let everyone catch their breath.
00:23:20
Speaker
You know, if obviously if there's a big procedure plan during that time, we might want to talk about things, but especially in these head injuries,
00:23:29
Speaker
Sometimes you just don't know how it's going to land or even in our multi-system trauma patients, you just don't know.
00:23:36
Speaker
And so I've actually like learned to kind of sit on my hands a little bit.
00:23:39
Speaker
I think because I want to be able to trust myself that my training, my palliative care training hasn't like led me to only think about death and dying.
00:23:51
Speaker
Because I also want to think about life and living and what that means, you know?
00:23:55
Speaker
And so I also think if a decision doesn't need to be made right at that moment, that why push someone?
00:24:01
Speaker
Because again, the family's just trying to catch up with everything.
00:24:04
Speaker
So yeah, I've become like a little more, I think I've just like try to walk down the middle of the road a little more right now, rather than like pushing for a decision right away.
00:24:18
Speaker
One of the things you just mentioned that I wanted to touch on, because you talked about kind of the four big prongs of the way you look at caring for these difficult situations, was care of the family.
00:24:27
Speaker
So you talked some about the transition for the family.
00:24:29
Speaker
So tell me more about kind of the things you do to take care of the families in these situations.
00:24:35
Speaker
Yeah, so I have to say, you know, probably the reason that I got very interested in hospice and palliative medicine was because of my grief experience after my dad was killed.
00:24:47
Speaker
And I just thought it was such a profound, lonely time where I didn't really have the language to talk about how I was feeling.
00:24:56
Speaker
And also when I found the language and I would tell the story, my dad was killed by a terrorist in Cairo, Egypt 30 years ago.
00:25:04
Speaker
And it's a crazy story and crazier because of all the things that happened after it.
00:25:10
Speaker
And when I would tell people this story, like they didn't know what to say.
00:25:15
Speaker
And I didn't find a lot of people who were able to hold space from my grief.
00:25:18
Speaker
And so I really got interested in...
00:25:21
Speaker
this medicine.
00:25:22
Speaker
Of course, I want to help patients, but I'm really interested in how the families are dealing with what are sometimes like these insane stories.
00:25:31
Speaker
And so I spend a lot of time with the family, like just holding space.
00:25:36
Speaker
Like I am, I will just say out loud, like, I just want you to know whatever you say is not too much for me.
00:25:42
Speaker
Whatever reaction you have is not too much for me.
00:25:45
Speaker
I'm just here to, I'm just here to be with you and you can say whatever you want.
00:25:50
Speaker
So that's one thing.
00:25:51
Speaker
It's just that idea of holding space.
00:25:53
Speaker
And sometimes that's a lot of silence, right?
00:25:55
Speaker
It's one thing we learn in fellowship is to be silent.
00:25:58
Speaker
And because in that silence is where all the emotions start to bubble up that people usually push down or avoid.
00:26:05
Speaker
If you're quiet long enough, people are start.
00:26:07
Speaker
It's amazing.
00:26:07
Speaker
People really do start talking and sharing.
00:26:11
Speaker
And then that, again, that idea of allowing them to avoid decisional burden.
00:26:16
Speaker
And I think that there's two ways to do that.
00:26:19
Speaker
One, not offering non-beneficial treatment.
00:26:21
Speaker
So we're not offering resuscitation when we know that it's going to be at least quantitatively futile.
00:26:28
Speaker
Sometimes it's qualitatively futile and you may offer it.
00:26:32
Speaker
But so we do not have to do that as physicians.
00:26:35
Speaker
We don't have to offer futile treatment.
00:26:39
Speaker
So that's one way.
00:26:40
Speaker
And two, instead of asking the families like, well, what do you want?
00:26:44
Speaker
I love the question that we learn in fellowship, which is, well, if your dad was sitting here with us, what would he say?
00:26:50
Speaker
So really putting it back on him, bringing him back in the room.
00:26:53
Speaker
And again, it's amazing.
00:26:55
Speaker
People are sitting around, they don't know what to do.
00:26:56
Speaker
And then you, I just had this a couple of weeks ago where I said, well, what would your mom want?
00:27:00
Speaker
Right away, they're like, take that effing tube out.
00:27:04
Speaker
That's what she would have said.
00:27:05
Speaker
And so I'm like, well, there's our answer.
00:27:07
Speaker
You know what I mean?
00:27:08
Speaker
And so that I said that was literally from the horse's mouth, you know, and so I love that idea of just really.
00:27:18
Speaker
trying to make it as easy for them as possible.
00:27:21
Speaker
And then, you know, I think we just mentioned like this idea of kind of taking that middle path.
00:27:26
Speaker
Well, you know, that middle path, I think is sometimes great for patients and families, but it can be really distressing for the team members.
00:27:33
Speaker
I think sometimes the nurses are like, they just can't wrap their minds around it.
00:27:37
Speaker
And sometimes I will take the time to talk to the nurses who I know are having their own distress and just reminding them, this is not about you.
00:27:46
Speaker
This you're going to in two days, you're going to forget about this day.
00:27:49
Speaker
And this is like the beginning of this family's grief journey.
00:27:53
Speaker
And so we have to honor it.
00:27:55
Speaker
And yes, it may be like a little uncomfortable and these orders may be a little weird.
00:27:59
Speaker
And I am here to talk to you.
00:28:01
Speaker
I, everyone has my phone number and they can call me whenever you want.
00:28:04
Speaker
But we're still going to do this because this is what's best for the patient.
00:28:08
Speaker
And, you know, during those times really for the family as well.
00:28:12
Speaker
So just making sure that the family just feels really supported.
00:28:16
Speaker
It's just so important to me.
00:28:18
Speaker
And I think for people, you know, there's a lot of, thankfully, I think a lot of young people I work with who haven't had their big grief event yet.
00:28:27
Speaker
And so I'm like, you know, you'll get it when they'll get it, right?
00:28:31
Speaker
Everyone gets it at some point and they'll understand.
00:28:33
Speaker
But for me, I know...
00:28:36
Speaker
that this is the beginning of their grief journey.
00:28:38
Speaker
And again, it can change someone's life.
00:28:42
Speaker
A good grief journey, the beginning of a good grief journey can really set someone
Addressing Moral Distress and Emotional Responses
00:28:47
Speaker
up first.
00:28:47
Speaker
I really appreciate hearing you talk about that because I think we get so much of our training is how do I deal with the nuts and bolts of the medicine?
00:28:55
Speaker
How do I deal with mitigating this person's disease process?
00:28:58
Speaker
And we do play such a big role in how the family is going to deal with that situation afterwards.
00:29:04
Speaker
Tell me, I'm curious, you're so tuned into the patient, the family.
00:29:07
Speaker
Tell me a little bit about what you do with the teams, because that's another big one.
00:29:11
Speaker
These patients are not just tough on us, and they're tough on our colleagues, and they're tough on our other people we're leading.
00:29:17
Speaker
So tell me about that.
00:29:18
Speaker
I think the first time I really recognized like moral distress was when I was a critical care fellow.
00:29:27
Speaker
And so really I was at UNC, spent almost the whole year just in the surgical ICU.
00:29:33
Speaker
So in like, you know, huge room, right?
00:29:35
Speaker
But it's still one big area.
00:29:38
Speaker
And I was so up close and personal with those nurses for almost a whole year.
00:29:44
Speaker
And I really got to see their distress.
00:29:47
Speaker
Like on some of these patients, I think transplants and patients, they, a lot of them can suffer and, and it's,
00:29:55
Speaker
sometimes notorious how, how long we will allow them to suffer for with hopes of a really good outcome, you know?
00:30:01
Speaker
And so I started to really appreciate like what the, the nurses were going through.
00:30:06
Speaker
And so as a palliative care fellow, and now as an attending, like I just, I feel like I do spend a lot of time just kind of checking in with the nurses.
00:30:17
Speaker
And then I'm really proud that we have a, um,
00:30:21
Speaker
was able to get this amazing man right now we have in our ICU who is a marriage and family therapist who not only sees our patients, but also works really closely with the nurses and the nurse managers to make sure that everyone's doing okay with whatever's coming in.
00:30:38
Speaker
So really supporting the nurses on that
00:30:40
Speaker
on that level.
00:30:41
Speaker
Like I said, like my phone number is posted in the ICU.
00:30:45
Speaker
I tell them, you can always call me.
00:30:46
Speaker
There's an end of life patient and you're just like, you can't handle it or you don't know what to do or you just don't want to give them meds, right?
00:30:52
Speaker
Sometimes they don't want to give them meds.
00:30:53
Speaker
They feel like they're killing someone.
00:30:54
Speaker
That's okay.
00:30:56
Speaker
Someone else will give them meds.
00:30:57
Speaker
Like you don't have to do anything you don't want to do.
00:30:59
Speaker
But what you can't do, which I've also seen,
00:31:03
Speaker
which really upsets me, is just ignoring the orders.
00:31:05
Speaker
And that you can't do either.
00:31:06
Speaker
We have to be grownups and talk about it.
00:31:08
Speaker
But I am always here to back you up, as long as you're reaching out for help.
00:31:13
Speaker
So I think that's the nursing level.
00:31:15
Speaker
I think there's this great man, Jonathan Bartels, who is a...
00:31:19
Speaker
He was a trauma nurse for a long time.
00:31:21
Speaker
Now he's a palliative care nurse in Virginia.
00:31:23
Speaker
And he came up with this idea of the pause, which is just taking a moment after someone dies, whether after a resuscitation, you know, a code, whatever, or just like a mess in the trauma bay where we just take a moment and, you know, one, honor the patient to like honor the team and really thank the team for just going above and beyond and, you
00:31:46
Speaker
than just like all taking a breath together.
00:31:49
Speaker
And then I also, lastly, like I really am interested in this concept of disenfranchised grief, which is, you know, it's defined as grief that we don't feel that we have the right to feel.
00:32:03
Speaker
So it's that feeling you get, you know, we all have feelings after someone dies.
00:32:08
Speaker
And then it's like, well, why am I feeling
00:32:11
Speaker
feeling this.
00:32:12
Speaker
This wasn't my loved one.
00:32:13
Speaker
Why am I crying?
00:32:14
Speaker
I mean, like that wasn't the worst day of my life.
00:32:16
Speaker
So it's almost like you're questioning yourself for your own feelings.
00:32:20
Speaker
And, you know, recently I was talking to one of our, um,
00:32:25
Speaker
respiratory therapist about this because I was in the room with a patient when she was terminally extubated.
00:32:30
Speaker
Her family didn't want to be there.
00:32:31
Speaker
So I said I would sit with her and the respiratory therapist came in and he took out the tube and it was just standing there.
00:32:38
Speaker
And I said, we're just chatting.
00:32:39
Speaker
And I was like, this must be really intense for you.
00:32:41
Speaker
I mean, you're really a huge part of so many end of life stories because you're taking the tube out, which is really the beginning of the end.
00:32:49
Speaker
Yeah.
00:32:50
Speaker
And I was talking to him about that idea of disenfranchised grief and that it's... We have to normalize feeling this and then being able to talk about it.
00:33:00
Speaker
It's not dramatic to have feelings.
00:33:03
Speaker
It's actually pretty normal to have feelings that you just contributed to the beginning of this person's end.
00:33:08
Speaker
Of course, the disease in the end is what's killing them, but...
00:33:11
Speaker
you know, we all had hands in it, right?
00:33:13
Speaker
I wrote the orders, the nurse pushed the meds, the RT took the tube out.
00:33:18
Speaker
And so talking about that concept and then normalizing everyone's feelings.
00:33:23
Speaker
And lastly, I am just so honest about my own feelings.
00:33:28
Speaker
Like I cry at the bedside.
00:33:30
Speaker
Probably every time someone dies, I cry.
00:33:33
Speaker
And I think that that just...
00:33:36
Speaker
I hope sets the stage.
00:33:37
Speaker
If other people feel the need to cry that they can cry too, you know, it shouldn't get in the way of our work.
00:33:42
Speaker
You know, I've learned in fellowship, you shouldn't be crying the loudest in the room, you know, but I would, I love, you know, but just like, I hope that they see if, if the surgeon's crying that, you know, it is okay to have, have your feelings.
00:33:59
Speaker
We have our feelings and then we go on to the next patient.
00:34:02
Speaker
And then I talk a lot about being in therapy because like,
00:34:04
Speaker
for multiple reasons.
00:34:05
Speaker
But I mean, I think everyone who does any of our, either of our jobs, right, could probably stand some therapy at some point in their lives, because we are all carrying this with us.
00:34:16
Speaker
There's no doubt that this sits on your soul.
00:34:19
Speaker
I mean, how could it not, you know, even if you're not naming it or aware of it, you know, your body's taking it in.
00:34:26
Speaker
So it really is amazing, the window we get to see into life and death.
Self-Care and Resilience in Healthcare Roles
00:34:33
Speaker
The other thing I was going to ask about, and you kind of talked about it, is really your level of emotion and your level of investment that you have in these patients requires you to take care of yourself.
00:34:44
Speaker
And having needed therapy myself for various reasons, I think there's a big value in that.
00:34:49
Speaker
It makes me a better clinician.
00:34:50
Speaker
It makes me better at taking care of other people if I'm taking care of myself.
00:34:53
Speaker
But tell me more about what you do to make sure that you can stay resilient even though you're dealing with really, really tragic situations on a regular basis.
00:35:03
Speaker
A lot.
00:35:04
Speaker
And it's just so interesting.
00:35:05
Speaker
I just listened to a great Ezra Klein podcast about self-care.
00:35:09
Speaker
And, you know, I think there's been a great commodification or gentrification of self-care.
00:35:15
Speaker
They call it the goopification of self-care, Gwyneth Paltrow's website.
00:35:19
Speaker
And, you know, when I think of, and, and, you know, I think on this podcast, they were talking about, you know, those things are fine too, whatever, you
00:35:29
Speaker
You do light a candle, do yoga.
00:35:31
Speaker
I mean, I've done all those journal.
00:35:33
Speaker
I've done all those things.
00:35:34
Speaker
But I mean, when I think of self-care, I think of like that really deeper work of self-care that I've been invited to or forced to do the last couple years.
00:35:42
Speaker
And to me, that's...
00:35:49
Speaker
therapy.
00:35:50
Speaker
I've like, have been very blessed to have, do some amazing work with internal family systems.
00:35:56
Speaker
And then with EMDR, which is such trauma informed therapy.
00:35:59
Speaker
And then I'm a huge fan of ketamine assisted therapy has, um, is just like a whole nother level of going through those, those layers.
00:36:08
Speaker
Um,
00:36:09
Speaker
For me, I work part time as a surgeon, one, because I developed multiple chronic illnesses after getting COVID that make my life really challenging.
00:36:19
Speaker
But it's also really forced me or invited me to slow all the way down.
00:36:26
Speaker
And it's
00:36:28
Speaker
And so that sometimes looks like a lot of sleep and looks like taking a bath every day and looks like saying no to a lot of things that I used to say yes to.
00:36:41
Speaker
And I think like that idea of self-care is just going to look really different for everyone.
00:36:46
Speaker
But I don't think that it has to be this idea of that it's like indulgent or selfish.
00:36:52
Speaker
What I have found in the end is like,
00:36:55
Speaker
Um, and again, this was more because I was forced by the world rather than like what I wanted.
00:37:00
Speaker
But what I realized in the end was if I don't do this, I'm not going to be able to do any of my job.
00:37:06
Speaker
And so now I think the idea of, um, self-care helps me to like, when I do show up to show up well and,
00:37:16
Speaker
And I think the one other thing of self-care that I've learned is the last couple of years is really trying to figure out what your values are, which is actually a really interesting, hard, like it's a really hard exercise to actually name like the few things that you truly value and then making all your decisions based on those values.
00:37:34
Speaker
Like that's, I think, a form of self-care that I didn't really understand until I
00:37:40
Speaker
Maybe even recently.
00:37:42
Speaker
And not everyone around you going to like it is going to like it because, you know, one of the values might not include working all the time, you know, or giving that 120% at work.
00:37:53
Speaker
You know, what if we all only gave 100 or sometimes we gave 80 and then our colleague gave 101 that one day and then you switch, you know what I mean?
00:38:01
Speaker
So yeah, there's a lot of different concepts there, but I think they're all important to talk about.
00:38:08
Speaker
I think they all have their place.
00:38:09
Speaker
And like I said, I really am very open and honest about my journey because I want other people to know there's all these options out there to get us out of some really rough spots.
00:38:26
Speaker
And I just want my colleagues to be
Closing and Expressions of Gratitude
00:38:28
Speaker
aware of them.
00:38:28
Speaker
It's really been a pleasure to be able to talk with you.
00:38:30
Speaker
I've enjoyed it thoroughly.
00:38:32
Speaker
You are a fabulous person and as you say on your podcast, you heal with more than steel.
00:38:40
Speaker
So I have really enjoyed this.
00:38:43
Speaker
It's been a lot of fun and I'd love to do it again.
00:38:46
Speaker
I think there's more things we could probably discuss, especially along the lines of just being a clinician and self-care and also mitigating the effects on our team members when we're all kind of seeing these difficult situations.
00:38:58
Speaker
But thank you so much for what you do and for advocating for palliative care and surgical settings and integrating these two fields together and really being a beacon to kind of get that word out to your colleagues.
00:39:08
Speaker
Thanks, Justin.
00:39:09
Speaker
It was so great to meet you.
00:39:10
Speaker
That was so fun.
00:39:12
Speaker
I've enjoyed it.
00:39:12
Speaker
All right.
00:39:13
Speaker
Thank you very much.
00:39:14
Speaker
And we'll have to do this again.
00:39:15
Speaker
Awesome.
00:39:18
Speaker
Okay.
00:39:18
Speaker
Thanks.
00:39:19
Speaker
I hope you have a great day.
00:39:21
Speaker
You too.
00:39:23
Speaker
For more information on current topics in the fields of palliative and emergency medicine, please visit palliem.org.