time to lead like an epidemic, launch multiple epidemics, and have an epidemic of leaders who know how to “epidemic.”
1 My No Good, Very Bad Night in the Emergency Department
You're gonna need a bigger boat.
—Amity Island Police Chief Martin Brody in Jaws
Friday Night in the Emergency Department
August 15, 2003, Billings, Montana
We begin in illness and injury. On this hot Friday evening, patients swamp the emergency department in the regional trauma center where I work. In the late summer heat, the night is just starting and has already flooded us with a raft of patients, and it promises to keep building. The waiting room overflows with more people. I have worked hundreds of nights like these in the previous decade plus, and I know the pattern. The quiet heat and the coming sunset belie the more ominous certainty of my shift ahead. People would get sick, some dramatically so. People would die. No one had gone about their day thinking these things would happen, but we know. In the emergency department, we check our equipment and ready ourselves with certainty.
As I cross the threshold of the automatic double doors into the department to begin my shift, I know it's busy even without scanning the electronic register we call “the board,” a remnant of the days when we used to list each patient and their chief complaints in bright dry erase marker on a big whiteboard before privacy concerns made it obsolete. I can hear the beeping of monitors, the shift in cadence of nurses' feet, and a low kind of ER buzz. The source is hard to pinpoint, like the low but incessant sound of unseen insect wings. To a casual observer, the department seems quiet, orderly, bright with fluorescent light. We like it that way—who wants to work in, let alone be sick in, a chaos of noise and motion?
The full cornucopia of unexpected disaster and discomfort bubbles out of the streets and homes and open spaces of life in America and flows into every room in our emergency department: automobile trauma, diabetes, cardiovascular disease, emphysema, diverticulitis, stroke, assault, cervical cancer, migraines, lacerations, domestic abuse, and opioids. The terms are medical and numbingly antiseptic, but the reality is stark: as the people of my town enjoy the warm summer evening, they are also crashing, dying, bleeding, fighting, and writhing in droves. While they go about their daily lives, they are part of a large, oddly silent tsunami of ill health that washes over the entire population.
No one is catastrophically ill at the moment, so I ease into my shift, getting labs and X-rays started on a few patients while I mentally accept that we will be working behind for a few hours. No one on the team likes working from behind. We prefer to stay ahead of the wave, seeing people as they come in. It is safer that way, and psychically easier for us. When the wave breaks over us, when we get behind, delays pile up and surprises happen, and surprises mean a higher chance of bad things for patients. Some nights, despite our best efforts, especially hot ones on summer weekends, the wave breaks, and we are playing catch-up. Tonight is one of those nights. The department has been behind since the afternoon, and it will be several more hours before we can get on top of the wave again.
The patients are varied, which is normal for us. The ER is the funnel for anything that can go wrong anywhere, at any time, for anybody. I see an obese patient whose knees hurt, a woman with vaginal bleeding, a middle-aged man with chest pain, a mom with back pain who can't lie down comfortably, an 80-year-old man with bad lungs. Nothing out of the ordinary, except I see all those people in the first 15 minutes, because twice that many wait unseen after that. I use my “30 seconds to meaningful rapport” to inspect and connect with each person I see. My trained eye scans breathing dynamics, skin color, tone of voice. I see eyes and facial expressions, plumb for fear or hidden motivations, search for the best way to settle every person who meets me for the first time in this place that is their bad detour and my daily work. My hands find theirs, and I rest them on shoulders and knees.
I step out of an older man's room into the low hum and look right, then left. I am impressed and grateful for what I see in the team of nurses, techs, registration clerks, and my emergency physician colleague seeing patients alongside me. Several years before, we weren't so much a seamless round-the-clock clinical team as a collection of technically proficient individuals. We couldn't elevate our game in the face of unrelenting pace. We didn't work that well together, and we weren't able to mesh the technical craft of our job with the human presence of connecting to each and every person who was ill, whatever their circumstances.
Eight years later, almost everything is different. More people come to us for care, and the metrics that define “good department” are positive: patient satisfaction and staff engagement have rebounded to high numbers from low ones, safety and quality metrics are strong, and the department sustains itself financially. Nurses are on a waiting list to get a position in the ED from other places in the hospital. Patients come by foot and ambulance, airplane and helicopter. Thank you notes dot the bulletin board in our break room, some with pictures of healed patients on vacations or hikes in the nearby Beartooth Mountains. Nurses, techs, and physicians work hard to help each other across the shift: quiet high-fives, thank-yous, and smiles pepper our interactions.
This night, we are at the top of our game. The patients are getting attentive and skilled care, and the team works fluidly without stress under the pressure of pace and pathology, moving fast without hurrying. We flex and bend to the needs of each patient and the staccato flow of the pace. As an emergency physician, I am at the peak of my craft. Well-trained and supported by capable nurses and skilled physicians alike, taught by thousands of patients, I am in the sweet-spot overlap of state-of-the-art training and sufficient experience, eight years out of a leading residency in my specialty of emergency medicine. I am comfortable on such weekend nights, at ease with the people I work with, the maladies and mishaps I would see, my own strengths and gaps as a clinician.
Despite the team's skill and my experience, a creeping dread wells within me as I scan up and down the hallway. It is my birthday, and while I am used to working holidays of all kinds and at all hours, this particular moment collides jarringly with all my years of effort, learning, triumphs, mistakes, hopes, and deaths in an unsettling pang in my gut and chest. In every room in our emergency department that night, while the ill and injured are getting what they need and we are chewing steadily at the backlog of patients piling into the waiting room, a bigger problem waits—no, grows—outside and beyond, unhurried, unstoppable, and inevitable. Nowhere does this unsettling gloom stick more than in my nose. The smell of blood, alcohol, feces, urine, antiseptic wipes, plastic tubing, vomit, and air freshener mix in my nasal cavity and settle like fine dust into my brain. Years before, when I was thinking of medicine and not yet doing it, I might have gagged. Now I just take a deep breath. It is not the smell of living.
“What you thinking, Scary Larry?” Dana, the charge nurse, appears at my elbow with a slight tug. “Big things or right-now things?”
She and I have worked together long enough to have earned our mutual nicknames for each other: Super Nurse and Scary Larry. I have worked with her while she handled two critically ill patients as the primary nurse while she held the charge nurse helm at the same time in the middle of the night. She can meet the wave. She knows my tendency to arc from micro-focus on the things at hand to macro meanderings on the source and end of what we see. She's more practical and fixes her mental gaze on getting through the shift.
“Big things,” I say.
She smiles, and the tug turns into a nudge. “Keep moving. We can hear about it later when it quiets down.” She gives me a wink before she moves past me: Shifts don't run us, Scary Larry. You and me—we run them.
As I suspected it
