Hope, Burnout, The Pitt and Andrea Austin!

We talk with Navy-trained emergency physician and author Andrea Austin about what war zone medicine taught her and why so many clinicians feel broken after years of high-stakes care. We name what sits underneath “burnout” and lay out practical ways to protect the people who are the safety net on everyone’s worst day.

The Book

The PITT

• Andrea’s path from 9-11 to military emergency medicine
• How the Health Professions Scholarship Program creates a long service commitment
• What changes when you practice resuscitation in a deployed war zone
• Why Andrea wrote Revitalized after a 2021 existential crash and sabbatical
• Moral injury vs burnout and how compassion fatigue shows up at work
• Complex PTSD in emergency medicine and why triggers can be unclear
• Why trauma often surfaces when stress finally drops
• The case for embedded therapists in the emergency department
• Debriefs, peer support, and how trauma can spread through team dynamics
• Boundaries, and how childhood patterns can reactivate in clinical work
• The “backpack” problem of unprocessed grief and the Body Keeps The Score
• Why The Pit matters for telling the story of emergency care and its cost

Transcript

Who We Mean By ER Docs

SPEAKER_01 0:00

Just a quick thing. As we get into this interview, I say ear docs, but what that is is a very global term. I'm talking about every nurse, every person who cleans up the poop, everybody that works in this setting. I'm using the term eadoc, but you all know who you are, and I do not want to disrespect any nurse, any respiratory therapist, anybody who's cleaning the floor, anybody that's working in this situation. So just accept that. It just makes it simpler.

SPEAKER_00 0:30

All right.

Navy Roots And Service Motivation

SPEAKER_00 0:31

So Andrea Austin grew up in Iowa and joined the Navy, went out to San Diego, and now I'm in beautiful Florida, and I've started a new emergency medicine residency program at Sacred Heart Hospital, affiliated with Florida State University and Vituity. Let's see. I think that's everything, right?

SPEAKER_01 0:52

It is so far from everything. Andrea Austin wrote a book. It's called Revitalized: a Guidebook to following your healing heartline. And we're going to get into that in a bit. But first we're going to talk to Andrew Moore. And I gotta say, I apologize that I have been not getting to the dirty white coat because my work at the pit is taking much more time than I thought it would. It's really important work. We are really trying to do a good job here. I don't know how long this show is gonna last, but while it's going, I really want to put in a good effort, and that means some of these other projects are gonna be a bit on hold until things settle, until said dust settles. And I have to do this, I did this a number of times, but Joe Sachs, who is my attending at UCLA, who is now my attending at the pit, is teaching me how to write. It's a whole new thing. He's shown so much grace, and I always have to shout out to my friend and mentor Joe. Thank you for putting up with me. Why I learn how to do this new thing. You taught me a new thing 35 years ago, you're doing it again. But enough about me. Tell us about why you joined the Navy. How did that happen? Was that in college? Was that to pay for med school? Give us that story.

SPEAKER_00 2:09

Yeah. So 9-11 happened when I was 16 years old. I remember hearing on the radio, back when we used to listen to radios, the news that the first plane had hit the tower. And that day was, you know, just it lives in all of our memories of people that are old enough. And, you know, we didn't do anything at school that day except um watch everything on the television. And that had never happened, where you spent a whole day at school just watching, you know, a world event unfold. And so it left a really big impression on me. And at the time I was already interested in medicine. And so I started to think, you know, if you're going to do medicine, you should do it in the most extreme way. And so I thought, if you, if I do emergency medicine, I want to do it in the military and uh be pushed to have to do things without all the usual resources. And if I can do emergency medicine there, then I can truly do it anywhere. So somehow I got that idea in my head. And I was also very service-driven. Uh both of my parents have done a lot of service throughout their careers, not in medicine, uh, but that those two things really came together.

How Military Medical Scholarships Work

SPEAKER_01 3:27

For our international listers in particular, how does that work? Because a lot of the time you can have the Navy, the Army, the Air Force pay for college or pay for medical school, but then you owe them service. So can you just fill people on how does that work?

SPEAKER_00 3:41

Yeah, there's a lot of different avenues, but one of the more common ones is after you're accepted to medical school, you can apply for a military scholarship through the health profession scholarship program. And for every year of medical school they pay for, you owe them a year. But for physicians, you owe them a year once you're fully done with residency. So it turns out to be a pretty long commitment. So that payback time didn't start until, you know, what was it, 2015, when I finished residency. But we were still involved in the same conflicts from when I was 16. So I did get my uh chance to deploy

Deploying And Practicing In A War Zone

SPEAKER_00 4:22

after all.

SPEAKER_01 4:22

So tell us about that experience. I'll I'll give you a quick anecdote at USC, County USC, one of the Navy training sites. And uh I would watch ER docs come out of residency from various places, hadn't deployed yet, come and work in this really busy trauma center, a lot of sick patients, kind of crazy, and they were a little bit awestruck. And then those same residents who then became attendings, who went off to deploy and came back, were completely different. They were the most experienced people in the room, the most calm, and we were the ones like, what happened to that person? So on deployment, how do you become such legends of emergency medicine?

SPEAKER_00 5:05

Uh, you know, it's it's very interesting because I went to a military residency and it was during a time where the operational tempo was very high. So my attendings were going, you know, sometimes every you know other year were deploying. And so in my residency, it was really baked in that this is, you know, what you're going to do. And we we had a lot of guidance on how you're gonna have to adapt your resuscitations. You know, how are you going to transfuse 30 units of blood into um, you know, potentially a quad amputee? And that's just not the type of trauma you ever, thankfully, we hardly ever see in the United States. So, you know, I think the first, so I had in my head what it was going to be like. And we'd had some very realistic simulations, and simulations is a big part of my my career as well. But there's no moment like the first time you're actually in that deployed setting. And I walked into the building that we were set up in, and I looked up at the ceiling, and there was rebar coming through the ceiling and from a prior mortar attack. And the ceiling was kind of caving in in that area. And I just kind of looked up and I'm like, oh, I am actually in a war zone. Like, this is actually dangerous. And that probably sounds really stupid to somebody listening, but there's really no preparing until you're actually there. I say that, but I was very prepared. You know, I can still remember my very first trauma patient, uh, severe burns, probably about 40% burns. Um, so seriously ill person. And, you know, we all gelled and it really amazing because that was my first time working with a lot of the people that were in the room, because that's what happens in the military. It's a lot of what uh Dr. Dan Dorcas calls form teams. You know, you're coming together and you don't really know everybody in the room.

SPEAKER_01 7:10

Well, you wrote a book called Revitalized, and in that book actually you talk about Carrie King and John, and these are 10 things that I was accounting with, just legends, just wonderful human beings and such good docs. So, why did you write this book? Tell us about it.

The Book That Came From Burnout

SPEAKER_00 7:24

Yeah. So in 2021, like a lot of people listening, I'm sure, uh, you know, the vaccine had come out for COVID and things should have been getting better. I should have been feeling like, you know, we're coming out of this really tough time. And that was actually when I felt the worst. And it was really this existential level crisis of I've spent my whole life, you know, working towards this goal of being an emergency doctor, and I don't know if I want to do it anymore. And I actually took a break. I took a three-month sabbatical. I still worked for the military. I was a civilian at that point. And I did some online teaching, went to therapy, got a coach. And at the end of that, I went back to emergency medicine, but very, very differently. And as I kept talking to more colleagues, and you know, emergency medicine continues to have the highest burnout rate, about 60% of our colleagues are suffering. I would share something I learned, and somebody would say, that's the first time I've ever heard that. And it just kept happening over and over again. And, you know, I think the same thing that draws us to help patients, I just couldn't stand that so many of my colleagues were in distress. I mean, I love emergency doctors, just like I know how much you love emergency doctors. And to feel to see that so many of us that work so hard can't feel joy in the work that we're doing on a regular basis. I just felt like an ethical imperative to consolidate everything that I had learned. And then I self-published very intentionally because I wanted to own the book. And I can send online copies to people. I can send physical copies to people, I never have to ask a publisher for permission. You know, it's funny when you go to publish a book, I've actually heard a few people say if you self-publish, you know, you're not in the author's club. And it's someday I will go through a formal publishing for another project. But this book being so personal about my life and what I wanted it to do, um, self-publishing was the right vehicle for it.

SPEAKER_01 9:50

Yeah, I self-published a book too for the same reason. Having that control was really important. So, what is the basic premise of the book? And I just want to tell everybody, go read it. The 60% number for burnout, I think, is uh understates what the burnout rate is. I believe it's close to 100%. It is just a very stressful job in a very stressful atmosphere. And every, every single doc I talk to has some level of burnout or just deep frustration. So without telling us the whole book, uh, what are some of the main themes that you get

Moral Injury Compassion Fatigue Trauma

SPEAKER_01 10:24

into?

SPEAKER_00 10:24

Yeah, uh I love that Dr. Brene Brown says that you can't really understand something until you have a word for it. And so there were a few concepts that once I learned about it helped relieve some of my suffering. One of them was what is moral injury and how does that differ from burnout? How are the two concepts related? Another concept we get into is uh compassion fatigue. And then the last one is trauma. And along with the burnout, you know, I would gather probably well, statistically, you know, they've researched this, about 40% of healthcare professionals um meet clinical criteria for post-traumatic stress disorder. And if we have time to get into it, I think discussing about complex PTSD, because I truly feel complex PTSD is what many of us are experiencing. And I felt it was really important to explain what complex PTSD was.

Complex PTSD And Hidden Triggers

SPEAKER_01 11:32

Why don't we spend a little time on I've not really heard that term outside your book? So what is complex PTSD? How does it differ from just good old-fashioned PTSD?

SPEAKER_00 11:43

Right. Well, it's it's very interesting. I always say, like, if there was a Venn diagram of emergency doctor plus military um physician, you know, what's my risk of suicidality or PTSD? Very high. You know, those are the two highest populations looking at occupations in the United States with post-traumatic stress. So classical PTSD, what many of us learned that maybe on our psychiatry rotation is a traumatic event occurs. There's a trigger associated with that. So for instance, if you were robbed at gunpoint outside of a 7-Eleven, every time you go past a 7-Eleven, that's your trigger. You might flash back, have physical symptoms when you're by that 7-Eleven. Well, for emergency doctors, we've had so many different traumatic events, so many different triggers. You know, you can think about smells, you can think about the way different patients look, different presentations, you know, the maybe the first patient you've uh ever had die or the first pediatric death. So all of those start to accumulate. And what's really tricky about complex PTSD is you don't even know what some of those triggers are. And then another feature of complex PTSD is something called an emotional lashback. So it's not that you don't know where you are or that you actually think the trauma is happening again, but you're having this emotional response that you really can't control. And you're going back to some emotional feeling, experience that you had, maybe under a whole nother different set of traumatic circumstances. So it really becomes a quite, as the name says, complex condition.

SPEAKER_01 13:38

Again, I think fairly universal. In my book, I outline my PTSD, which occurred sort of after I finished working clinically, and you have that sort of reckoning of your career, and I kept having terrible flashbacks of dead children that I'd looked after. And it kept happening. And my wife was like, You need to get some help because I just start crying. Yeah. Because I kept seeing these kids' faces. Is that the kind of thing that you're talking about? There wasn't even a trigger that I was aware of. It was just I could see the resuscitation and how badly it was going, and then having to tell the parents, and it would just come out of nowhere. Not even, you know, it's not even like I was held up at gunpoint. It was just, it would just happen during the day.

SPEAKER_00 14:17

Yeah. I mean, I'm not a psychiatrist, but to me, that does sound like an accurate description of complex PTSD, because it's not a clear trigger. And I think what you're describing is incredibly common. You know, throughout our careers in emergency medicine, when we stay at this heightened stress level, a lot of times we're not able to process all the trauma that's happening. And similar to what happened to me in 2021, as the stress was coming down, is when I started to feel, you know, that I was falling apart. You know, trauma, you know, there's a famous book written about trauma that I'm sure many listeners have heard of, The Body Keeps the Score. And trauma will always come out. And the other reason I find this so important to get out to our community is our patients are experiencing trauma, just by definition of being in the emergency department. If they weren't traumatized before they got to us, being in the waiting room probably uh traumatized them, which the pit does such an amazing job of showing what it's like being a patient in a waiting room. And patients that are experiencing trauma can also be very challenging and I'll even say annoying to deal with. And so by understanding our own trauma, you know, it's made me more compassionate to our patients. And also I hope, I hope that I'm minimizing the secondary trauma that they're experiencing in the emergency department by having a little bit more insight into, you know, why they may be acting the way that they're doing it. Again, it's not an excuse. And we know in our profession we experience workplace violence. It's not an exp excuse for aggressive behavior, but it is an explanation and just understanding what toolkit may be helpful in that situation.

SPEAKER_01 16:11

Yeah, it's a really helpful section of the book to help you get back some of that compassion to understand that many of our patients are suffering what we're suffering from. But in order to have that compassion, you have to understand that you're suffering from it.

Therapy As Training And Prevention

SPEAKER_01 16:23

And so what do you say to your residents, your faculty members, about how they should think about their career, knowing that so many of us will have PTSD? How do you front load some therapy for these people?

SPEAKER_00 16:37

Yeah, I mean, I would love us to get to a point where, you know, it's a JACO, you know, we think about all the Jaco requirements that don't make sense. Um, I think a Jaco requirement that would make sense is embedded therapists, right? We know this job results in occupational hazards that have huge emotional issues that then lead to physical issues. We know having PTSD, depression, anxiety is going to increase your risk of cardiovascular disease. So I would encourage, and what you know, we're going to start resident orientation very, very soon is have a therapist. You know, I have a psychiatrist and she shared with me during her last visit with me that she has a psychiatrist. I'm like, whoa, the psychiatrist has a psychiatrist. There's, you know, and I so appreciated that honesty. You know, I do think it was so funny. A few years ago, I'd been in therapy for a couple of years after COVID, and I was going to the Veterans Center, which I talk about in the book. And that's a free service available to veterans, but I'm also very sensitive that I um have a lot of privilege and I make a physician income. And so I was feeling guilty about using that resource. And so I said to my therapist, I said, you know, I feel like I'm doing really well and I don't think I need to come every month. And I want to open that space up for somebody that's, you know, suffering more than me. You know, we have homeless veterans. This when I was living in San Diego. And she looked at me and she smiled and she said, Andrea, you have a very stressful job and you are going to continually be traumatized by it. So I'll see you next month. Let me worry about how everyone here gets cared for. You focus on taking care of yourself. So that was such a powerful reminder. So I would encourage my residents to have a therapist. And here's the other thing that was really important to get out in the book is we all have different childhood experiences in this concept of ACEs, adverse childhood events. I would encourage everyone to go take that, it's readily available online to take your own ACE assessment. Yes, we you're you're a physician, you're in healthcare. Obviously, you've exhibited high levels of coping and adaption. But what happened to me, and I think happens to a lot of people, is by being in the healthcare profession, some things from your childhood can be reactivated. And so therapy is really good at helping you recognize what were some of the patterns in your family, how was conflict handled, boundaries. You know, my house was a very low to no boundaries zone. And that led to a lot of problems early in my career. And so I think therapy is really important. And then I think peer support and community, which, you know, you've done such an amazing job creating throughout your career. You know, MRAP is a community. Yeah, those are just a couple of quick thoughts.

SPEAKER_01 19:41

There's so much there to unpack, and it's really unpacked uh so well in the book, which again I encourage everybody to read. There is this idea that a few things that you touched on. One was I don't deserve therapy, or I should not need it. Look at me, I'm a physician, I've achieved at the highest levels. Like, no, you need therapy. I had the same reaction when I uh developed PTSD and I was getting ketamine therapy, and I was walking into the ketamine office with this wonderful team, and there was a gentleman outside with terrible schizophrenia. He was actively psychotic in the streets here in LA, and we see it a lot. And I went in and had the same reaction. I'm like, this doesn't seem fair. That guy's brain's on fire, and he's not getting any help. And here I am, a rich, privileged physician, and I'm gonna sit on a nice couch here and get ketamine therapy. And they had the same reaction. You not getting therapy, Mel, is not gonna help him. So let's make sure that you're well so that you can go and help him. And it was really profound because I had so much guilt about the privileged status, and there is so much untreated mental health. I love that story uh that you tell. We deserve to get care. Everybody listening deserves to get care. And my therapist, who is wonderful, has a therapist. Just the same as your psychiatrist.

SPEAKER_00 20:58

Yeah, yeah. Oh my gosh. I mean, it's well accepted in the mental health community to have their own mental health professionals. So, you know, we we say as scientists, as physicians, that we believe in science and expert opinion. So we're gonna believe expert opinion on vaccines, on what medications to prescribe. But when the the mental health professionals say that they have their own mental health team, we're going to say no, no, we don't need that.

SPEAKER_01 21:34

You said something about embedded therapists.

Embedded Therapists And Team Debriefs

SPEAKER_01 21:36

And and I've said a number of times now that I believe every ER doc, probably ever every ER nurse, should be in therapy. But are you suggesting that maybe there should be a therapist in the ear? Like not necessarily individual, but in the ear looking after the whole team.

SPEAKER_00 21:52

After the team, you know, and I think every emergency department is so different. And I think you Know there's plenty of mental health happening in the emergency department. And so maybe it's a dual role. Uh, I think in the best circumstance, they would be dedicated just to us. And believe me, there's enough dysfunction happening in emergency department. But I I would see them having this role that they could help lead debriefs. And I'm I'm a simulation educator, so it's not that I can't lead a debrief, but maybe they're co-facilitating that debrief. They're observing behaviors. I would love for them to be have a mental health background and a coaching background and hopefully coach people up because we see some opportunities. You know, one of the other things that happen is traumatized people traumatize other people, right? And so how much of our trauma is related to poor leadership, poor communication. It's a pressure cooker. And again, the pit does such a great job of showing it. And, you know, everyone loves Dr. Robbie. But then, you know, people talk about, well, sometimes Dr. Robbie's a jerk and he's mean. And I have been Dr. Robbie before. Totally. And to have somebody observing that could maybe take someone off to the side and say, you know, hey, you need a break. Or, hey, how about you let's make an appointment next week? There's there's a few things we could maybe get into. I really think of it, you know, it's been portrayed on so many different movies that police have to go see a psychologist, right? After they use their service weapon, they got to go in and see the mental health professional. So when we use our equivalent of a service weapon, a laryngoscope. So I'll tell you really a story that would have been such a great day to have had a therapist in the emergency department.

The Mother’s Day Case And The Backpack

SPEAKER_00 23:42

I worked Mother's Day. This just happened a few days ago. And my mom was coming into town, and my husband wanted to pick her up in my car instead of his truck. So he dropped me off at work. So it almost never happens that he drops me off. And I turned to him and I said, the only wish I have today is that no mothers die under my care. And I said that and I walked in, and within the first hour, I had to intubate an older mother and go talk to her daughter. And she ended up dying. And then I took care of another mom that was really severely severely injured. And so I had to go talk to her daughter. So I had to, you know, be with two daughters on the absolute worst day of their life on Mother's Day. And that had never happened in my whole career. And it really like I had tears. I definitely had tears. And nobody on the team, and I have the most lovely team, nobody stopped to like kind of like take that all in that day. So where did all that go?

SPEAKER_01 24:50

My purpose has this saying, nobody gets away with anything. That trauma doesn't go away. Another way I've heard it described is, oh, I've got to see the next patient, the next patient expression. So you take that trauma of these terribly sick families, their mums dying, and you put it in your backpack. And you're like, I'll get back to that later. And you don't. And months go on, years go on, sometimes decades go on, and their backpack becomes so full it just pulls you over and you topple. That's just a terrible story, but that's what ER docs do all the time. We have to unpack that, we have to find the time to talk about that, or the body keeps the score.

SPEAKER_00 25:29

Yes.

SPEAKER_01 25:30

And the body will make you pay.

SPEAKER_00 25:32

Yes. Absolutely. And I mean, we need we need healthcare professionals so much. And that's what really, you know, keeps me up at night is thinking about what's going to happen to our workforce. Who's going to care for us? You know, who's going to be there for us when we need emergency care? You know, my husband makes this joke all the time that, you know, is the plan to send half of the country to medical school, you know, because whenever something happens to me or to a family member, you know, I have to fill in the cracks of our system, right? Like

Why The Pit Matters And Closing

SPEAKER_00 26:10

if I'm not advocating and figuring out how to get it to work, then my family member or me won't get the care that we need to get better. And that's really concerning.

SPEAKER_01 26:22

Well, I love the ideas that you have in your book. I think it's so important. I really encourage every ER doc, nurse, family member to read your book. It's really practical, has some great solutions. I can't thank you enough for writing it. It's really personal to talk about these stories and to write it down and very courageous. And thank you for your service and thank you for your ER doc service. And thank you now for your mental health service. What you're doing is really important.

SPEAKER_00 26:49

Right back at you. You've been a huge inspiration along the years. You know, the um hashtag that you developed of what you do matters. And I mean, that's on days that I felt like maybe what I do doesn't matter. I've tried to have you in my ear that that that's a temporary feeling. Um, that what we do really does matter.

SPEAKER_01 27:10

Thank you, Dr. Austin. You're an inspiration. So if you got it to the end here, thank you. I just want to say again, I'm kind of want to apologize for the fact that I started a number of projects before I got the privilege, the absolute privilege of being uh invited to work on the pit. And thank you again to my mentor, Joe Sachs. There's a number of us. There's Joss Chroke, me, Joe Sachs, a number of docs on the sets, many nurses putting this thing together. I think it's a really important show. I wouldn't be here if it wasn't a really important show because frankly, I don't want to commute and do all this stuff. But it's a really important show. And Joe's teaching me how to write for television. And Joe taught me how to be an ER doc 35 years ago. It's really important. Not sure how long I'll stay on the show. Not sure how long the show will be part of the Zeitgeist. But I know right now it's really important because it's telling the story of what you do, of the stress, of the incredible interactions that we have in a way that MRAP actually never has done because it can't. And I just want to say to all of you again, thank you for what you do. Thank you to the pit and thank you to Joe for bringing me on. But mostly thank you to you, the people that do it. I have some nurse friends, and uh we talk about what was the thing that happened on the pit this week? And they text back and say, Sorry, didn't watch it this week. I was actually doing it. Oh Zhang, you're actually doing the thing that we're making a story about. But that's the point, right? We're trying to make a story about the thing that you are doing day, night, weekend. You're heroes. So for now I've decided like this show again in this time frame, this site, guys, is probably the most important thing I can do. And once it's over and it's time will come and go, as all these things do, I will jump back into Emra and Victus and you fully. But just I just want to say, I want you to understand that I'm doing this Hollywood thing for now, because I think it's the best way to highlight what you do. Because what you do matters. And I'm trying not to be a bullshitter here because you know, I got my own existential crises, and being in Hollywood is fun and everything, but I'm pretty sober, I'm pretty clear about what really matters. Because you, it turns out that you are the safety net. You look after everybody on the worst day of their lives. Every doc, every nurse, every tech, every person that cleans the floor, you are the safety net. And I'll be back soon. But for now, a little bit of Hollywood stuff.