Road to Resilience
Road to Resilience
A Day in the Life of an ER Doc
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Every day, emergency departments see people on some of the hardest days of their lives. In this episode of Road to Resilience, host Stephen Calabria speaks with Dr. Nicholas Gavin, an emergency physician at Mount Sinai, about what it really means to work in the emergency department.
Dr. Gavin offers a simple but powerful perspective on resilience: it is a muscle that can be strengthened. By looking back at how we have navigated adversity before, we can draw on those experiences to face whatever comes next.
To register for our upcoming livestream panel commemorating the 25th anniversary of 9/11 and the transformative work of the World Trade Center Health Program in clinical care and research, visit mount sinai dot org forward-slash wtc event for more info.
Visit https://www.mountsinai.org/clinical-trials to see if you're eligible to enroll in a clinical trial with the Mount Sinai Health System.
Check out more episodes of Road to Resilience —as well as guest pictures, transcripts, and more— on the Mount Sinai website.
If this episode inspired you, please consider supporting the Mount Sinai Health System. As a registered 501(c)(3) nonprofit, we rely on philanthropy to advance compassionate patient care, groundbreaking research, and medical education. Your generosity helps make conversations like this possible—and fuels the work behind them. To learn more or make a gift, visit give.mountsinai.org.
Visit https://www.mountsinai.org/clinical-trials to see if you're eligible to enroll in a clinical trial with the Mount Sinai Health System. Check out more episodes of Road to Resilience—as well as guest pictures, transcripts, and more—on the Mount Sinai website.
The following episode contains depictions of traumatic medical events some listeners may find unsettling. Listener discretion is advised. From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Steven Calabria, Mount Sinai's Director of Podcasting. Every day, people walk through the doors of an emergency department on what may be the worst day of their lives. Sometimes a family arrives with minutes to spare, and an emergency physician has to make a life-changing decision with only the information in front of them. But what does it actually mean to work in an emergency department? On this special edition of Road to Resilience, we take you inside a day in the life of an ER doctor with Dr. Nicholas Gavin, an emergency physician at Mount Sinai. Dr. Gavin walks us through the rhythm of an emergency department, opens up about the moments that stay with you, and ultimately about the role of resilience. Why it isn't about being unaffected by adversity, but about allowing yourself to feel it and learn from it and to find a way forward. Dr. Nicholas Gavin, welcome to Road to Resilience. Thanks for having me. What would draw someone to work in emergency medicine?
SPEAKER_01Aaron Ross Powell So I think when I was considering what type of doc I would be, first of all, I had the background of growing up in New Jersey and serving as an EMT on my town's first aid squad. That was my first exposure to healthcare. I was the first doctor in my family, so I didn't have some image of what a doctor might look like. So worked on the ambulance as a 15-year-old. I walked in and said, what you guys are doing is pretty cool. How can I help? And started to get exposure to emergency medicine. And my first call as uh I was a first responder. So you could become an EMT in New Jersey when you're 16. So I was a first responder when I was 15. I was literally just riding on the ambulance and carrying stuff for the team. My first call was an opioid overdose in what turned out to be a halfway house in my town, my little town in New Jersey. It was like about a mile from my house. It's an opioid overdose. Ended up being an HIV-positive sex worker who was living about a mile from my house, overdosing on opioids. I saw the team engage in a resuscitation that saved this person's life. And slowly over time, you start to see that compounded by all of the complex social and medical issues that are happening in communities. And I realized just being a doc, just addressing medical things, just understanding the biological underpinnings of disease and physiology is not enough for me. It's about the social underpinnings of care. And that's what still excites me about emergency medicine. It's the real intersection of social care with healthcare. All of society's problems show up at the front door of the hospital, and it's our job to try to address them.
SPEAKER_00So walk us through a typical day dealing with all of those problems. What does the average shift in an emergency department actually look like from the moment you arrive until the moment you head home?
SPEAKER_01Yeah, I work in an academic health system at Mount Sinai. We work eight-hour shifts, the rotating shifts. We work 24-7, 365. There's no ability to close the doors at any moment. We work morning shifts, evening shifts. We stack our shifts so that we're staffed to demand, right? So late at night, three in the morning, there are fewer people walking through our door than one o'clock in the afternoon. So we have more docs and more residents and PAs and nursing staff. So it's an eight-hour shift. I work with an incredible team of physician assistants mostly and residents. So we have trainees, interns through PGY4. It's a four-year residency program. And then on the team is our nursing colleagues. We have pharmacists who are embedded in the emergency departments. When I walk through the door, I say, all right, this is my team for the day. And it's always people you know, but it's always a rotating cast of characters. And then you're assigned to an area. Our emergency department is divided into the fast track, the lowest acuity area. Some people refer to it as a mid-track, or we call it our acute area of people with chest pain and belly pain. Their vital signs are okay. That's a sort of our middle acuity area. And then we have a critical care and resuscitation area so that you sort of know you're walking into all of the sickest patients who walk through the doors of Mount Sinai Hospital are coming right to you that day. So the day can feel completely different based on any of those dimensions. Are EDs more active in the morning or at night? I would think at night. Aaron Powell EDs peak between 10 a.m. and 2 p.m. Actually, what shows up through the door changes, right? During the day, the whole health system is awake and alert and getting phone calls from patients and saying, this is what happened overnight last night. What should I do? And doctors' offices are open and they're doing procedures and figuring things out and patients' diagnostic journeys. So actually, the vast majority of the volume comes through during the day and it starts to taper off at 8 or 9 p.m. One cool thing, I've done a lot of work in emergency department operations over the course of my career. And what we like to say is we can kind of predict, and this has gotten to be more and more of a science over time. We can predict how many people are coming and when. We just don't know their names yet. So there is a science to the flow and the rhythm of emergency departments.
SPEAKER_00Emergency physicians are expected to make life-changing decisions in a matter of minutes. I imagine it comes down a lot to the training, but how do you stay calm when nearly every decision carries enormous consequences?
SPEAKER_01Yeah, I think it's probably about two things. It's training and muscle memory. It's also really having a sense of what you have control over and what you don't. And I think that is a skill that I like to bring into my personal life, frankly. One of the most powerful things that was said to me in a clinical setting was in residency, I did residency in Oakland, California. And we had a patient who came in without a pulse, they were dead for all effects for all purposes. And I was an intern, I was like newly a doctor. And one of my attendings said to me, Nothing you can do can make this situation worse. And basically what he was saying, like, this can't get any worse. Everything you'll be doing is with the intent to get a better outcome and to move up from here. So even in the most high pressure situation, you say, I'm going into this situation with the best of intentions. I'm going in with a skill set that I've developed over at this point, 25, 30 years, and I'm making prospective decisions based on the data that's in front of me. And I feel pretty good about that.
SPEAKER_00Aaron Powell That was a situation where nothing you could do would have made it any worse, but that's not always the situation. Was there a moment in your career when an especially difficult shift fundamentally changed how you think about resilience and how you think about your job?
SPEAKER_01I remember having to tell a family that their 14-year-old son had died of a gunshot wound. And it was out of the movies. There was blood everywhere, his backpack was on the ground. I remember telling his grandfather, who was his big caretaker, his parent, and just watching this big man crumble. And I remember trying to stay calm, trying to you get training on this, but then when you're actually doing it and giving someone the worst possible news that you could provide, it's a really different thing. And you're trying to just stay calm and provide some reassurance that your professionalism translated in the care of that patient and everything was done that could be done, but also being human and just saying, I am so sorry. This is the worst possible moment for you, and how can I possibly be here for you? I remember walking away from that conversation, not having given way to emotion, and just going into a call room and just losing it, just totally losing control of my emotions in what I would now say is a very positive way, right? I was allowing myself to feel what was going on. And there are moments like that in an urban emergency department in our cities every day, where our providers, our nurses, our staff are just faced with things that they shouldn't be faced with. And I remember saying out loud to a colleague, this is just too much. This is just too much. But I think you bring the badge of professionalism to say, this is part of my role in society, to try to be there in whatever way you can as witness to take from that experience something that can be translated to something positive and really be a vehicle of service. That's what you're there to do. And that I think is what being a doctor is all about. But the resilience piece is being able to walk away from that situation and at some point go back to being your best self. Something like that happens, and quite frankly, it's not possible to be your best self. That is very front of mind for a while. But understanding that you heal, people heal, you take that knowledge with you and you move forward. Again, you try to find the silver lining of this happened. I want to work on this. And I can tell you 50 stories like that, where 30-year-old patient who I saw and over and over again in our emergency department in Oakland had metastatic gastric cancer, the diagnostic delay after diagnostic delay, died on hospice in our hospital, pivoting from that to going to work on the process of saying we identify a problem, here's how we're going to short circuit all of the bureaucratic pieces that get in the way in healthcare delivery in the United States. That can be very healing. And turning those horrible moments that lead to grief and resentment and anger into something actionable, that's how some of how I've become resilient.
SPEAKER_00I imagine your job also entails a lot of compartmentalization. You can't go full in really, because how do you keep that up every single day, just veering from triumph to tragedy. And then right back again. How do you emotionally transition from one patient to the next without carrying the weight of every single encounter?
unknownYeah.
SPEAKER_01A couple of things here. So number one, I've had a pretty diverse career at this point. I see patients once a week if I'm lucky. There are many really R docs now that are seeing patients four days a week, 32, 36 hours any given week. And that really is their day-to-day. So I just want to qualify that, number one. Number two, it's fine for television to dramatize what we do in the emergency departments. And I think there's a lot of work that's been done, I'll say recently, that is a really good representation of what happens, particularly in urban emergency departments around the country. But the truth is, most days there's not a ton of drama. There's little things that you find in the system that are broken, that are frustrating, that cause moral injury. But it's patients with falls and broken bones and belly pain, chest pain, et cetera. It's not an everyday experience that it's some overwhelming, terrible thing. Part of being an emergency doc or certainly an ICU doc or others, death and dying is a part of life. And that comes about from trauma and from cancer and a variety of different causes, some feeling more or less tragic than the others. But it is part of life. And again, just being witnessed, being helpful to the people that are left and around it, and being helpful to the people that are in and around illness. One of the things that we're thinking a lot about right now is like, how do we support caregivers as we move into this silver tsunami of people aging in the United States and like having no support? What are we going to do? So I guess what I'm trying to say is the search for meaning is every day in the ER, but it's not an every single shift kind of phenomenon of feeling broken by what you're witnessing. Mostly what you see is humanity doing its best and people stepping up in their families and nurses grinding it out and working for patients and supporting families and nurses sacrificing their bodies and their mental health to support the patients that we serve? You see the best of humanity.
SPEAKER_00We've talked about not only resilience, but also process improvements that can be made and often are made as far as the ED goes. One of the biggest frustrations patients talk about is ER wait times. Yep. From your perspective, what are the biggest factors that determine how long someone may have to wait in the ED?
SPEAKER_01Yeah. So there's two pieces of waiting that I would break into two different challenges. There's waiting to be seen, there's the front-end waiting. One of the real crises that we're experiencing in the country right now is waiting to be admitted to the hospital. These are two distinct, semi-related problems, but it's not a direct line, meaning there could be hospitals that are high performing on your weight to be seen at the front door and low performing on your weight once somebody decides to admit you to the hospital. There are hospitals in this city where you can wait 24, 36, 48 hours to get into a bed after somebody has decided that you need to be admitted to the hospital. So on the front end issue of waiting to be seen, it really is the mathematic problem. Like I said, we know how many people are coming, we just don't know their names yet. So we staff to that. We staff to getting orders in on patients shortly after arrival across the Mount Sinai Health System. If you go on Mount Sinai.org right now, you can now see the wait times for all of our emergency departments across the health system. We're trying to be more transparent about that. We're trying to say we want to hold ourselves to the standard that we would want for ourselves and our family members when we show up at emergency departments. At almost all of our sites, that number is right around 10 or 11 minutes on average for all patients who are walking through our front door. That's something that we're incredibly proud of that emergency medicine leadership has been really focused on. That requires intentional effort to say we are not going to allow anybody to slip through the cracks and wait to be evaluated by a provider shortly after they present to our emergency departments. We know that the job of triage is incredibly hard. That's the hardest job in the hospital, the nurse who's sitting at the front door of our emergency departments. So we need a second layer of a provider to see patients and make sure that those who have critical issues are being addressed up front. If the issue is waiting to be seen up front, it's number one, a leadership problem. And number two, at certain times during surge and certainly during winter flu season and that kind of thing, it can be a legitimate space challenge where just from a safety perspective, you can't get patients back and into the emergency departments. That tends to be a fringe issue at this point. On the hospital side, when patients are waiting to be admitted to the hospital, the challenges are what are the incentives for length of stay and throughput through the hospital? So when you're waiting for an inpatient bed, it's not an emergency department problem, it's a hospital problem. So why is that patient who's up on the floor, who's in the bed that you would be occupying, why is that patient still there? Is there an insurance barrier to getting them through? Are they not clinically getting better? Do they have family support at home to take them home? All of those pieces need to be run like a well-oiled machine in order to make sure that the hospital is leveraging those beds as efficiently as possible. So just want to highlight those are two distinct cues: the wait for a provider and treatment on the front end, and then an inpatient bed on the back end of that.
SPEAKER_00While long wait times can be incredibly difficult for patients, they can also be all but equally difficult for physicians, nurses, and the rest of the care team who know people are waiting and suffering but can only move so fast. What kinds of strategies are employed behind the scenes for those who are doing everything they can yet still feel like they're falling behind?
SPEAKER_01Yeah. Managing acute care in our largest city is an unsolvable care of a problem, right? I guess what I would say is we ask for grace from our patients and their family members when we are pulled in different directions. No one should wait for care, particularly if they're in pain, particularly if there's a critical diagnostic issue. We use our tools to the best of our ability to try to determine based on what we see at the time, again, prospectively making decisions. We dedicate resources and allocate resources in a way that we think is matching with the presenting acuity. So for folks who are coming into emergency departments around the country to have that presumption and to give the grace to say, I'm waiting because somebody else is sicker. I'm waiting because there aren't limitless staff members. That's why I'm waiting. And the humans who are working their hardest in front of you are not to blame if I'm waiting. That's what we appeal to. I don't know that I have any special tricks that we've deployed to help with that. Other than one thing we've been thinking about and working on is we've deployed some digital tools to help people know what they're waiting for. A lot of times when patients are frustrated, it's like, I don't really know what's next. So we're working on digital tools to make that more transparent. Inside of My Mount Sinai, we have a tool called Track My ED Visit. And it basically says, these are the meds you're getting, this is the diagnostic test you're waiting for. That's not the perfect solution, but it's some part of the way of just lifting the black curtain and saying, here's what we're working on.
SPEAKER_00Well you touched on my next question, which was technological solutions or interventions into the process being the next chapter in how we address these sorts of issues. And you yourself have even helped lead innovations in emergency care and virtual agent care. What other things are popping up that people should know about?
SPEAKER_01I think there's so much happening right now and there's so much opportunity. I think I would highlight a few things. One is I think we're positioned really well at Mount Sinai to make sure that only the patients who need to be in the emergency department should be in the emergency department. So we've tried to make it really easy to access a provider, a qualified emergency provider, by the way, seven days a week through my Mount Sinai. So you can access, have a conversation with someone, try to avoid an emergency department visit or even an urgent care visit by getting on the app, going and seeing a provider in that way. We've even built out a care model that we call message only care. If you have a really simple problem, you have a red eye or a STA, you're a woman with a urinary tract infection or a yeast infection, we're saying you don't even need to do a video visit with a provider. You can do a message based visit, you can share an image of your eye. We can try to take care of that through just basically chat. We accept those chats 24-7, 365. We respond to them within an hour during business hours. The next day, if it's submitted overnight, what we provide back 75% of the time is a prescription, anticipatory guidance, next steps. That's pretty cool. 75% of the time, we're completely eliminating the need for you to have a video visit or an in-person visit for a simple low acuity problem. All of that care, the virtual care in the home, is going to be accelerated by home-based diagnostics. Simple example, we started to see COVID tests. We have flu tests in every pharmacy now. People shouldn't be going to urgent cares for these things. They should be doing video visits with a qualified provider, maybe even doing asynchronous visits for those types of things. There's not a ton to do if the diagnostics are done correctly and we can do the diagnostics in the home. So that's a lot of what we're focusing on in terms of acute care in the home. What we're trying to do in the emergency department is leverage artificial intelligence and other new technologies to just make everything much more streamlined. As an example, we have a partnership with a company called ADOC AIDOC. It's the largest basically diagnostic radiology AI company in terms of FDA cleared algorithms, basically surfacing insights from the images when we capture them. So I get a CT scan of your abdomen when you come into the emergency department, surfacing those AI insights both to the radiologist and maybe even to the care team so that we can say, Stephen has appendicitis, let's act on it right now. That's incredibly exciting and an opportunity for us in the year ahead. Just an example of how we're eliminating time from what can be a strenuous and long journey for patients in the emergency departments.
SPEAKER_00Strenuous journeys aren't just experienced by the patients, obviously. They're also experienced by the physicians. Burnout in particular has become an increasingly important conversation across healthcare, but especially, I imagine, in the ED. What habits or perhaps mindsets would you say help ED docs and nurses and all those working in the ED to sustain a career in this particular field?
SPEAKER_01Yeah. And frankly, I used to make fun of it. I was one of those people that was like, yeah, that's not a thing. Like Burnout among doctors is not a thing. Burnout among doctors is not a thing. And I think it was because I just loved look, the job is hard. It's not meant to be easy. It's a choice, right? We make this choice to go into this career. By the way, I love my job. I love the diagnostic dilemma. I love being the first person to try to come to a diagnosis or help somebody. But I was hit in the face with this during COVID and around that time of like just real moral injury being in a system that wasn't working for patients, wasn't protecting me and my colleagues in the way that it should. And you don't mean Mount Sinai necessarily. No, I actually wasn't at Mount Sinai. Oh, okay, good. Yeah. And moral injury and burnout is real. It's caused by systems. It's not caused by patients. Because I think it can feel like adversarial, right? Like you were describing the wait times where patients get frustrated and they take it out on the care team. And you can feel like you're being pitted against each other. We are on the same team. When you show up as my patient, my nurse, myself, we're on your team. We're like there is no presumption. That's one of the beauties of my specialty is we're not allowed to say no to anybody. We are an all-comer sport and we're on your team. It's the system that gets in my way as an individual provider. It gets in the way of the nurse and it gets in the way of the hospital, frankly. The incentives get in the way of doing the right thing. Again, turning that on its head and saying, okay, the system causes burnout. The system causes the friction and that potential adversarial relationship between providers and patients. So how can we improve the system? We create these virtual care systems, we create these digital tools to provide information to lessen the burden on providers of sharing that information, being frustrated on their clinical shift. I think you turn that burnout, those pebbles in your shoe, into something positive for the person who's sitting in your seat tomorrow, the patient who's arriving the next day, that's pretty powerful. That's how I partly address burnout. The other piece is just really focusing on investing in your own health and mental health, spiritual health, physical health in the same way that you invest in your career, right? Doctors are the worst at I worked 80 hours this week. I barely attended to my family around that. And it's like, did you eat something nutritious? Where did you actually eat a meal slowly? When did you work out? When did you take a step back to think about how life is going and what you want to do next week? So I think being more intentional about self-care and and your own personal health, being intentional in the same way that you would be about your career and where you've gotten in terms of patient care.
SPEAKER_00Aaron Powell For those who believe the burnout is a thing and have experienced it themselves, how do you advise folks to decompress after they've finished their shift? You've mentioned you're not in the wellness space, but insofar as you counsel the members of your staff, let's say.
SPEAKER_01Yeah, I think for me it's been physical stuff. Getting outside, working out, taking care of myself, being away from screens. Because actually in our emergency departments, we're like constantly at computers, right? We're up and running, we're talking to patients, we're back at the computer, back at the computer. I would guess on a given shift, I'm spending 60, 70% of my time sitting at a computer. I don't know that anybody's actually studied that, but it's got to be around that number. So like disconnecting digitally and moving my body. Those are the things that I recommend to other people.
SPEAKER_00If someone listening has never been to an ED, what can they do before an emergency ever happens to make the experience smoother for themselves and their loved ones?
SPEAKER_01Aaron Powell That's a great question. I'd uh highlight a couple of things. One is that think about where you're going. Do people really undercount continuity of care within health systems? We're really trying to operate as a system. When you show up in a Mount Sinai urgent care, they have access to your whole record. It's really easy for them to see everything. Same thing, you go to the emergency apartments, you go to our clinics, our walk-in clinics, and our urgent cares. It's one record. It's one Mount Sinai. If you are a Mount Sinai patient, if it's at all possible for you to get to a Mount Sinai facility, that's actually a big value add. So that's number one. Take a step back and say, can I take five extra minutes to get to the place that knows me the best? I really strongly recommend that. Number two, and I guess for chronic patients with chronic conditions, I would say having an accurate medication list of these are the things that I'm currently getting treatment for and keeping that up to date and having that ready to go, whether that's a note in your phone or an actual physical piece of paper, or ideally it's your health record, there are challenges there that are more on our side than on the patient's side. But having an active list of what's going on with you is another thing. And then I would also say, especially when coming to emergency departments, if you don't need to be there by yourself and you can have an advocate there with you, bring somebody with you. You're scared, you're in pain. Having somebody to bide that time with you to serve as your advocate is something that's helpful from our vantage point. And it's something that I've seen as incredibly helpful for individual patients over the years.
SPEAKER_00Staying calm and not letting the situation penetrate your psyche and your emotions, you're surrounded by people who care. Finally, if there's one lesson you've learned after years of caring for people on some of the hardest days of their lives, what would you want every listener to remember about resilience?
SPEAKER_01Aaron Powell I think no matter where you are in your personal journey, you have a story of resilience inside of you. I think resilience sadly is a muscle. You can grow it. You have that experience inside of you. So if you're facing something, it's looking to those examples of inside yourself, inside your family, inside someone that you love and you can look at how they dealt with adversity. But going back inside yourself and saying the last time I faced adversity, these were the principles that I abide. I think can be an incredibly useful method for saying, I've been in this spot before. Here's how I'm gonna address this this time. And also, frankly, like getting better at it, but getting better at dealing with adversity. It's a muscle and it can get better. We can get better at it.
SPEAKER_00Last question. What do you say to patients who use the ED as just their regular doctor? Who just show up when there's an issue?
SPEAKER_01I say all are welcome here.
SPEAKER_00Dr. Nicholas Gavin, thank you so much for your time, sir. Thank you. Thanks again to Dr. Nicholas Gavin for his time and expertise. That's all for this episode of Road to Resilience. If you enjoyed it, please rate, review, and subscribe to our podcast on your favorite podcast platform. Want to get in touch with the show or suggest an idea for a future episode? Email us at podcasts at mountcinai.org. To register for our upcoming live stream commemorating the 25th anniversary of 9-11 and our medical system's response, visit mountcinai.org forward slash WTC event for more info. Please consider supporting the Mount Sinai Health System. As a registered 501c3 nonprofit, we rely on philanthropy to advance exceptional patient care, groundbreaking research, and medical education. Your generosity helps make these conversations and our mission possible. Learn more or make a gift at give.mountsinai.org. Road to Resilience is a production of the Mount Sinai Health System. It's produced by me, Stephen Calabria, and our executive producer, Lucia Lee. From all of us here at Mount Sinai, thanks for listening, and we'll catch you next time.
