Waking Up

Waking up, I smile …Thich Nhat Hanh

The last few months have been a time of personal and professional awakening.

Waking up to the physical reality of being human. Of having to accept I am not immune to the impact of the relentless pressure of the pandemic on my Emergency Department, nor to the devastation of the HSE cyber attack. And that even if I pretend otherwise, my body knows and sooner or later illness is inevitable.

It’s also been a time of pragmatic awakening. To the reality of life as a coloured doctor in Ireland. Acknowledging the presence of a systemic discrimination that is so deeply embedded it is practically invisible to those who perpetuate it. And more importantly, adapting to what is and isn’t deliverable to patients when their care is provided for by someone of colour.

Awakening is true when accompanied by action. And actions are true, when they come from a place of love, rather than from one of fear or hate.

For me, a first step is coming back to the core practice of loving kindness (“metta”). To hold in love and understanding the pain and suffering I see in and around me. And from this place of compassion, to explore how I can best use this precious life energy to alleviate suffering and discrimination.

Resilience 3.0 and Refugee Boats

A lot has been said about the “unprecedented” nature of the Covid-19 pandemic and of its impact on health care.

An Emergency Department perspective on Covid however is perhaps a little more nuanced. While the scale of the pandemic was certainly unprecedented for EDs across the world, the scope of Covid-19 wasn’t. Emergency Departments have regularly dealt with and / or prepared for viral outbreaks – influenza, SARS-Cov-1, Ebola among others.

To me, what is truly unprecedented in both scale and scope is the impact of the cyber attack on the HSE. Never before would we have imagined shutting down an entire network of computers across a national health care system.

As we move into week 2 of the shutdown, this is my perception of its effects on departmental energy levels.

Social energies are up. Replacing emails with actual conversations and a sense of coming together in a crisis are boosting connections.

Intellectual energies are recovering. From an initial feeling of “cerebral nakedness” – not having access to patient records, previous reports, test results or online clinical references – to finding work arounds and coming back to good old fashioned clinical medicine.

Physically, people are tired. This is a labor intensive environment – there is no getting around it. For now at least.

Psychological safety has taken a big hit. The timing of the cyber attack – just as Ireland was coming out of a lockdown that stretched since December – could hardly have been worse. National activity is rising, accidents and emergencies are rising in tandem, Covid measures are still in place – all while the ability of the ED to respond to this surge has been dramatically reduced.

Why am I writing about any of this ? Partly to keep my own note of these events. And partly to explore – how should I / do I respond ? Is my inability to gauge the spiritual energy level of the department a reflection of current conditions – or of me ?

Academics and researchers have written much about resilience. Yet for me, what a world wise friend shared this week is what resonates. Resilience is simply surviving. Surviving 15 months on the frontline facing Covid, surviving this cyber attack, surviving what else may come and doing so with spiritual strength. A spiritual strength that comes from remembering – these conditions too are impermanent.

So coming back to the root question of this reflection – what compassionate wise action can my best self bring to this situation ? I am reminded of a story from Thich Nhat Hanh and the answer emerges – presence and solidity.

“When the crowded Vietnamese refugee boats met with storms or pirates, if everyone panicked all would be lost. But if even one person on the boat remained calm and centered, it was enough. It showed the way for everyone to survive.”

WPW – Beginning Anew 2021

The graph says it all. As the third wave of Covid hit Ireland, it was all hands on deck. Projects had to take a back seat.

Now as we move through the Spring Equinox, it feels like the time has come to get back on the horse. People and projects have had a bit of time to mature and adapt to a new healthcare world of long term Covid. The tracking system I mentioned in my last post is in place. And I see at least a few green shoots of renewed interest amongst our registrars and some managers to improve ED-hospital systems (beyond Covid).

The unsaid risk however – the proverbial elephant in the room – is recognising the huge toll Covid has taken on healthcare staff who were already over stretched – even before the pandemic hit. An Emergency Department nurse from a near by county provides an unfortunately accurate first person account – that resonates across hospitals all over Ireland.

A delicate journey lies ahead. What Joan Halifax describes as an edge state – where the “five virtuous human qualities” of “altruism, empathy, integrity, respect and engagement” can either lead us to courage and freedom – or slide into a mire of destructive suffering …

WPW – Week 6 RPR

“For wood to burn and release its light, it must be given space.” Zen teaching

Any concerns I may have had about losing momentum were easily laid to rest this week. The ED registrars leading on different projects are moving forward with a core energy that is a privilege to nurture.

It feels like the time is right to set up a new page tracking progress more formally than these end of week blog entries. Work for the week ahead.

Closing this weekend with the personal nourishment of attending a Peaceful Hearts retreat and understanding more deeply the roots of compassion.

WPW – Week 5 RPR

This week’s surprise lesson for me was experiencing how it can be quite stressful to be kind to oneself. Might sound paradoxical, yet this was my direct experience.

Simple practices – like letting the computer screen hibernate for the 5-7 minutes I have lunch, finishing my shift on time, allowing myself to not eat the fast food brought in by a well wisher and instead have a salad pre-prepared for work… Simple practices of self compassion and self care that should feel easy – but didn’t. Similar to the initial discomfort that comes when (re)learning a skill.

A big positive for the week – recognising this week’s ‘pause’ provided the team with the kind of time and space that nurtures psychological safety. Will this be at the cost of losing project momentum ? Or will individual and team motivation be boosted instead ? We will find out as the new week dawns …

WPW- Week 4 RPR

“I saw the angel in the marble and carved until I set him free.” Michelangelo

The stand out moments for me this week have mostly been around 1:1 development time with different members of our wider ED clinical team. Letting them grow and spread their angel wings as I hopefully reinforce their sense of autonomy, authenticity and ways to engage.

The most precious encounter was with one of the registrars taking care of a patient who visits our ED frequently. This time though, the registrar was able to shift his focus to work with that part of the patient that keeps coming back to the ED for help – instead of the part of the patient that makes her relapse into destructive behaviours as soon as she leaves. This change in intention opened a whole new path for both the patient and the registrar (who had seen her several times before with the same problem.)

Compassion in practice, one patient at a time.

From a systems point of view, the ED older patient flow pathway we put forward last week has been accepted and the pilot starts tomorrow. A record breaker for getting stakeholder engagement (not to mention agreement !) so quickly.

For the week ahead, my intention is to prioritise some self care and self compassion. To remind myself of what I share so often with my team – when we pour for others, we must sometimes stop to fill our own cups too.

WPW – week 3 RPR

The external growth this week has mostly been in the intellectual and physical energy domains. Notably – delivering the first session of a training program I am offering to ED clinicians interested in quality and clinical audit. And upgrading a proposed ED geriatric referral pathway to a patient flow pathway – shifting the central focus back to the patient.

Diminishing psychological safety at the organisation-ED interface has been the challenge for a second week running. I find myself coming back and taking refuge in the spiritual domain of our work – a purpose and perspective that helps me acknowledge the suffering without it becoming overwhelming.

Serenity to accept what I can not change, courage to make the changes I can, and experiential insight to recognise the difference. Compassion in practice.

WPW – week 2 RPR

Positives this week – seeing leadership and new confidence express itself in an ED registrar’s board round. Plus nurturing the leadership wings in a member of an ED Frailty Intervention Team (that I am responsible for).

The monthly ED journal club continues to mature, in particular relationships and shared learning between the registrars. An opportunistic teaching moment this week – reinforcing the ethics/integrity that must be at the heart of everything we do as clinicians – research and beyond.

My most difficult moments this week – experiencing the physical symptoms and the hit to psychological safety that arise from management meetings without good governance. Observable changes in concentration, mood, energy levels, headache – not dissimilar to carbon monoxide poisoning!

Personal area to grow – allowing myself the self compassion to focus on what matters most and let go of career aspirations that necessitate carbon monoxide type toxidromes.

WPW – week 1 RPR

Feels like a good week. The Europe wide research study our department is participating in connects us with a bigger picture and higher purpose, nourishes social engagement and provides a channel for physical action.

Also protected some 1:1 time with ED Quality Improvement Project registrars. Helped them understand the difference between medical research and quality improvement. Reinforced the importance of a moral compass – looking deeply and understanding where our (project) volition comes from.

Personal positive – concentrated most of my time and energy on my sphere of influence. Action and agency.

Personal area to grow – meeting people where they are, and not where I want/expect them to be ! Balancing the real life time pressure of delivering on research and departmental change while still providing young minds a safe space to learn.

Compassion in practice.

WPW – Work Place Wellbeing

What does “human factors” mean in an Emergency Department world of Covid 19 and how can my ongoing training in it make a difference to where I work ?

As a first step, I am introducing Zoom based sessions on quality improvement methodologies, adapted to my local setting. Gently redirecting attention from our circle of concern to our sphere of influence – individually and collectively.

My belief – action and agency in these difficult times help relieve suffering and maybe even promote well being in the workplace. Compassion in practice.