Lakshman Swamy (laxswamy@bsky.social) Profile picture
Jun 27, 2018 17 tweets 8 min read Read on X
Burnout: a work-related constellation of signs/symptoms, often without prior psychiatric history. Marked by existential crisis, emotional exhaustion, and depersonalization. That’s academic. I described what it looks & feels like at @MassGeneralNews @acgme @TheIHI [THREAD]
Early in intern year, I was caring for Mr. V, an elderly HD patient. 1mo earlier, he was living independently & working at HR block. Now, he was admitted with delirium. I couldn't figure out why. I couldn't fix it. Weeks went by. He floundered on the service, sicker by the day.
After 14 inpatient days, we finally diagnosed Mr. V. Months before, PCP prescribed Morphine CR- normally cleared by the kidneys, but his didn't work. It made him sleepy enough that he missed HD once, the start of a downward spiral. Perhaps an error was made that day by his PCP...
But the real error was that morphine was still on the ACTIVE MED LIST, given 2x/day for 2 WEEKS. I was poisoning him. I fixed it & Mr. V was lucid... but it was too late. He had chest pain. I stepped out to get an EKG. When I returned to the room, I was alone. He was gone.
This hit me hard. Really hard. I had just started as an MD and I felt singularly responsible for a medical error that killed a man.

I worried it would happen again, that I was the problem. It was the beginning of an EXISTENTIAL CRISIS- starting with the imposter syndrome.
Took a long time to shake off "I'm not good enough for this work."

... but 5 services were involved including renal & palliative, pharmacists & RNs who deal w this every day- EVERYONE missed it. A systems error led to my 'reduced sense of accomplishment,' to existential crisis.
What about EMOTIONAL EXHAUSTION? As an intern, @paullongMD cared for a man w osteomyelitis 2/2 IVDU. MRI showed extensive bony destruction, unclear acuity. Needed recent scan from hospital nearby to compare images. No problem, right? Paul makes the calls, sends a request...
Gets report, no disk. Calls again, disk made, but not mailed. He sees pt daily, ashamed, asks for more time. Pt is itching to use. 5am one dark winter AM, Paul bikes to the other hospital, effortlessly gets the disk. We review images. Plan: surgery. Paul goes to patient's room...
…only to find an empty bed. Pt eloped, never seen again. Soul crushing for intern who "moves mountains" to get things done only to fail. Repeat all year and you get EMOTIONAL EXHAUSTION. You stop trying. You CAN'T try anymore. Broken systems lead to emotional exhaustion.
Depersonalization, now, that’s a strange word. Let me explore it with a story from the amazing & inspirational @RanaAwdish. Rana was 7mo pregnant when she presented to L&D at her hospital with excruciating abdominal pain. She is terrified and on the verge of hemorrhagic shock...
The OB resident is at her bedside to ultrasound baby. Rana is an intensivist & ultrasonogropher, so she makes the diagnosis first. “there’s no heartbeat.” The resident, staring at the ultrasound display, says, “can you show me where you see that?"
She had just realized that her child had died in her womb- while critically ill. The resident was entirely oblivious.

Soon after, she is a patient in her own ICU (!)

Resident visits, plans to apologize... but ends up in tears, complaining about how hard the night was on him!
I can imagine how he felt: ashamed. When I've felt that degree of shame, I withdraw. No one understands it, so I pull away. Relationships wither with patients, colleagues & family. Everything is replaced with cynicism-- that's DEPERSONALIZATION, a consequence of broken systems.
So that's burnout - existential crisis, emotional exhaustion, depersonalization.
Or, to put it more simply, "the light inside is broken but I still work," (for now) - - thanks @psirides for the photo.
When our systems fail us, they wound us, and that wound can fester. It isn't an accident, because "every system is perfectly designed to get the results it gets” - Paul Batalden & Arthur Jones
Burnout has an impact on everyone, not just the clinician. Patients have lower satisfaction & increased harm, especially increased nosocomial infections & medical errors (more errors w higher burnout scores) and higher mortality rates. #ptsafety nam.edu/clinicianwellb…
For more info check out the @theNAMedicine resources on wellness. More coming soon as I begin my research at the intersection of burnout and #ptsafety in the ICU! nam.edu/burnout-among-…

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More from @laxswamy

Sep 24, 2023
I often teach the a few core principles of what makes ICU decision making different from treating what appears to be similar problems on the med-surg floors. Here are a few principles I emphasize, in no particular order...🧵
1. Think pressors, not fluids.
💊On the floor, low BP ➡️ IVF bolus. But in ICU, patients, physiology, monitoring are all different. Short term peripheral pressors are generally safe, but repeated IVF can be harmful. If the pt already rec'd IVF, think pressors.
2. When using fluids, think bolus, not maintenance.
💊There are good indications for mIVF (a slow drip). But I rarely use it in ICU.
- I want to see the response to IVF - a bolus allows for that. We can watch to see the effect real-time. You can give small boluses too.

Also...
Read 12 tweets
Apr 25, 2023
Thank you all SO MUCH! I ran the Boston Marathon!! ALL of your support carried me through one of the hardest, most joyful, most exhilarating experiences of my life. I ran to support mental health... 🧵 Image
Mental health hits close to home for all of us. I had the great privilege of running in honor of my uncle, Nagendra Prasad- Babu Uncle, who lived with me through much of my childhood. You'll see his name on my singlet- it gave me a huge boost when I heard the crowds cheering him! Image
Babu Uncle has lived with debilitating paranoid schizophrenia since his 20s and self-medicated with cigarette smoking for much of that time. I grew up seeing this firsthand in our home, leading to me spending a year and a half studying the impact of schizophrenia on smoking. Image
Read 10 tweets
Apr 11, 2023
Thinking about the acute care experience of caring for patients w self harm / attempted suicide. What is it like when you care for someone immediately after a 'medically serious suicide attempt' ?
- how do you think you can help them?
- how does caring for them impact you?
- >700k people die by suicide every year: 1 person every 40s. 1.3% of deaths worldwide in 2019
- Occurs at all stages of life; 4th cause of death in 15-29 years of age
- People w a 'medically serious' attempt are more likely to die by suicide in the future
https://t.co/1cNFUiBu66bmcpsychiatry.biomedcentral.com/articles/10.11…
Image
I often feel powerless when I care for a patient with a 'medically serious suicide attempt' (MSSA). Often the ICU is monitoring in case things get worse, or sometimes providing life support to get through the acute phase...
Read 12 tweets
Apr 10, 2023
In 1 week, I'll be at the starting line for the Boston Marathon. I hope I will already be across the finish line for my goal to raise $20k for mental health. I am working in the ICU this week and seeing the profound impacts of mental illness everywhere I look... Image
People with severe anxiety from one of the scariest things we experience- not being able to breathe-- and living like that every hour of every day. The devastating impact of substance abuse- especially alcohol and opiates.
The dread and depression that are sometimes even worse than the cancer diagnosis.

The impacts of mental health extend beyond my patients- the families of those who have lost someone in the ICU and will carry that deep grief for the rest of their lives...
Read 8 tweets
Feb 2, 2023
I had the chance to give a talk on the Quintuple Aim and a vision for the future of quality. I'm sharing some of the highlights from my talk, "QUALITY: AIMING FOR THE FUTURE" 🎯 🧵
I open with the original Institute of Medicine (now @theNAMedicine Domains of Quality- hopefully old news by now!
Crossing the Quality Chasm, A New Health System for the 21st Century. https://t.co/efTIF3Xs3h https://t.co/OqoaBaOj5pahrq.gov/talkingquality…
psqh.com/analysis/impro…
Image
A common response was "we can achieve any of this, but not all of it." That's why the TRIPLE AIM was revolutionary: you not only can do all 3, you CANNOT sustain any Aim independent of the others.
@donberwick et al. The Triple Aim: Care, Health, and Cost. Health Affairs. 2008 Image
Read 25 tweets
Nov 16, 2022
Twitter allowed us to create something different in medicine. I think it's special for these reasons:
🔸Transparency
🔸Content
🔸Flattened hierarchies
🔸Low barrier to entry
🔸Voice
Here's what I mean...
🔸Transparency = public accountability. Less locker room talk. Patients & the public hear us & engage, generally raising the bar for the conversation, bringing in diverse perspectives, and forcing some degree of professionalism. Unlike what we see in some closed groups on FB.
🔸Content focused; although amplification is a focus, the discussion is built on content. It's fundamentally different to build on words w images & videos rather than focusing entirely on the snippet. Twitter threads can be long and detailed with many refs/links... Unlike IG.
Read 9 tweets

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