Paul Austin, Author of Something for the Pain: One Doctor’s Account of Life and Death in the ER

May 27, 2009

Dr. Kent: Welcome back to the show. My next guest is Paul Austin, and he’s the author of a book called Something For the Pain. The ER is a place that we see on television in sort of glorified light, and we see in real life as sort of a more difficult life. Hopefully we won’t have to see the inside of an ER too much, but we appreciate the doctors so much. It’s my honor to speak to Paul Ethan Austin. Welcome to the show.

Paul Austin: It’s my pleasure.

Dr. Kent: So tell me about this book, Something For the Pain.

Paul Austin: The title Something For the Pain, the subtitle One Doctor’s Account of Life and Death in the ER. It’s about the way my job almost wrecked my family. It turns out that the ER can be a really stressful place to work. There’s an abundance of human suffering. It turns out that you work rotating shifts, and at least in my case it turns out I took a lot of stress home with me. So one of the major points of the book is the way in which someone’s job, you can bring that stress home with you and it can damage your family and your relationships in your family, and kind of what I did to kind of mitigate those factors.

Dr. Kent: It appears like we had a little station break and I apologize for that difficulty, and I’m back on the show now, live. I welcome myself back on the show, and we have Paul Austin, the author of Something for the Pain: One Doctor’s Account of Life and Death in the ER. We still have you?

Paul Austin: Yeah, I’m still here.

Dr. Kent: Sorry about that. So tell me, we were in the middle of, the ER is not only difficult for, obviously there’s scores of people waiting in the waiting room, thinking about their families, and scared about their loved ones, but that stress kind of carries on, it sort of sticks to your clothes when you go home.

Paul Austin: Yeah, it really can. That’s probably true with a lot of different jobs. This job is, the need is so great, there’s so many people who have a very valid claim to your time and attention. Sometimes the ER can kind of be the bottom of the funnel of the people needing to come into the hospital, and we’re trying to get people in and out safely and quickly. Understandably people can get really impatient. Nurses, more so than docs, but just about anybody that works in the ER, the people can take out their frustrations in way that they wouldn’t in their doctor’s office, or at an upscale restaurant or bar. Sometimes people can, understandably, vent their frustrations. Add that to people having heart attacks, or people in a car wreck, or someone who’s not breathing, their could be a lot of other serious medical problems of which these are all kind of a background. So the nurses and docs, and nursing assistants and ward clerks and housekeepers, all the people in the ER have to kind of figure out a way to give good care and be emotionally present to the people who need it, but yet keep their own defenses up. So that’s another aspect of the book, is how can one remain compassionate in what has become an increasingly industrial environment. So that’s another theme of the book, is how to kind of regain your compassion if you get burned out, or how to understand what compassion means.

Dr. Kent: Well, I know when I was in the emergency room I had a doctor there who made me feel really at ease, and it’s such a strange place, it’s not meant to be a warm and inviting and friendly, but at the same time, what does a doctor do to save patients’ lives, to make the at ease? And how much of that do you take with you, and how much can you leave behind?

Paul Austin: I’m glad you had a good experience. I’m so relieved for people who say they went to the ER, and they may have had to wait a while, but the doctor was nice, or the nurses were nice, or the people were competent. I think a lot of us that work in that environment are just hoping that the person we talk to had a good experience, because it can be a place where people wait a long time. Sometimes a doc or nurse may speak sharply when they don’t mean to, and I’m so glad you had a good experience. One thing that I’ve come to think about compassion is that it’s not an emotion. When I started as an undergraduate I was working my way through college as a nursing assistant in an emergency room. I was the guy who cleaned out the bedpans and pushed the stretchers to take people upstairs, and did that to pay for school. At that point I thought that compassion was an emotion, I thought it was something you felt. I have come to believe that it’s more of a discipline, that it’s more of a habit. It’s a work habit, just like a carpenter keeps things plumb and square, a carpenter measures twice and cuts once. A carpenter makes sure the angles are right before he nails it together. I think a good doc or a good nurse views compassion in a similar way. I think it has less to do with emotion and more to do with maybe philosophy or one’s personal belief system about the role of caring for people. I’ve come to the conclusion that it involves kind of opening your heart and closing your heart as a situation demands. Like, if someone comes in that’s critically ill, or they’ve stopped breathing on the way in, that requires a sort of, there’s kind of a drill that docs and nurses do together, it’s very much a team, and we kind of all know our roles, and it’s more like a pit stop at a race track than it would be an emotional event. It’s more of a technical event at that time. You really need to close down your emotions. You need just to function quickly, and efficiently and pleasantly and professionally, and without feeling much. Then later, you may need to open your heart some. It’s like if a mom comes running into the ER and her baby’s blue and not breathing, and the heart’s not beating. They hand it to the nurse, and the nurse comes running back to the ER and says we need a doctor in Room 7 now. I go in, and the nurses are trying to stick IVs in the baby, put an airway in, you put a tube down their windpipe. And then the next step is to get IV access to give them meds or fluids for whatever they need next. Often just opening the airway will do a whole lot towards resuscitating a child that age. But say you’ve got an airway in, you’re breathing for the baby with a little bag through the tube down their mouth and into the windpipe, and you’re stuck on IV. The nurses have tried a couple times and have not been able to get an IV. The next step is to establish an intraosseous line. That’s an IV that goes into the bone of the tibia. The lower leg has two bones, pretty good sized bones, called the tibia and a smaller one called the fibula. But you just stick a needle right into the bone itself. The fluid goes into the bone marrow, and from the bone marrow into the bloodstream. And it gets into the bloodstream almost instantaneously, it’s almost as good as an IV and it’s a lot faster. And to do it you just hold the baby’s little leg in your hand, and the needle’s kind of like a finishing nail. It’s a pretty good sized needle, and it’s got a little pea handle on it, and you just jam it down into the bone. You hear kind of a crunchy little pop as it goes into the bone. So it goes into the skin and through the muscle and pops into the bone. If it wiggles, it’s not into the bone. It needs to feel like a nail that’s been driven into wood to know that you’re in the right place. And then you hook an IV tube and then you go to the next step. That process of jamming a needle into an infant’s lower leg is kind of a brutal procedure. The child doesn’t feel it because they’re functionally dead, or out of it, but you practice on chicken bones, on chicken legs, at least when I was training that’s what we did. But you feel, it’s not something you feel much about. You just pop through that step and go to the next step. You bring a very, not a harsh persona, but you bring a, you want to get things done attitude to do that procedure. Now, when you talk to the mom, or the dad, you can’t bring that forceful, stick a needle in the bone personality, that would be cruel. You have to kind of open your heart and take a deeper breath and relax your shoulders and unclench your fist when you’re talking to the family. So that’s kind of a little quick example of a time where you need to be kind of harsh, or hard, kind of bring something forward that will squeak us through a problem, and then kind of open up, and soften up. What I’m trying to do, and what I think I’m getting better at doing is closing down my emotions when I need to, and opening them up when I need to. Sorry to talk so long.

Dr. Kent: Well no, it’s fascinating, and that kind of insight is, especially with these shows on television that are so obsessed with the ER, and you wonder how much of it is right, and in a lot of cases it really is brutal stuff that you have to do, but you have to do it to save people’s lives. It makes a lot of sense that you can’t come up to someone and say I just rammed a needle into your baby’s bone. You can’t do that, right?

Paul Austin: You can’t say the baby’s got a heartbeat, but probably going to be brain dead.

Dr. Kent: Right, exactly.

Paul Austin: You can’t say that. In the room, once you get then, say you get a pulse, yeah, you can’t be just real blunt with people, that would be cruel. I think TV shows do a great, great job at what they’re good at. They’re real good at getting the sights and sounds of an ER. Like if you watch that TV show ER. I’ve seen copies, I’ve seen a show or two. Not recently, so I don’t know if it still does it, but it did a real good job of getting kind of that pace, getting that sound, getting the feel and texture of the moment. I think they do an incredible job with that. They don’t, very few TV shows are able to kind of get beneath the surface of what the spiritual experience of it is, or the emotional experience, or the real experience is. And that’s what the book, I was hoping, in the book I wanted it to be as much literature as a book. I want it to have literary value just in its prose, just in the way the nouns and the verbs work on the page. I want them to be good. I was just thrilled when Norton decided to publish it, they’re my publisher and they’re known as a big, literary press. I was just so thrilled that I had at least my editor’s satisfaction, or created a work of literary value, as well as a book that’s kind of pretty honest about what my job’s like. But I think that literature can get at that. I think a good book can get at what’s really happening on the human level, or where your heart is level, more than maybe a TV show.

Dr. Kent: Right. Part of the reason this book is unique is that it’s something we really all experience in our lifetimes, the ER. If you’ve recently been to the ER with a family member, you might not want to watch a show like ER because it’s so real-seeming. But what’s your take on, you talked a little bit about it, but doctors really do need to steel their emotions in some ways. I don’t know, I think a lot of people don’t know if they could do it, in terms of where you start out in med school, operating on cadavers, and then you’re dealing with painful things all the time. How do you steel your emotions to do it?

Paul Austin: I think getting the emotional armor up into place isn’t that big a challenge. At least for me it wasn’t, maybe for my classmates and colleagues and co-workers it is. I think that the bigger challenge is how to poke some holes in that armor. What can happen is that, ok, you’ve seen the ER. I don’t know about other types of medicine, but maybe in radiation oncology, where it’s kind of a foregone conclusion that people have an illness that will probably be terminal, and all we’re going to do is shrink down the tumor enough to ease the pain, or gain a couple years survival. It may be in that situation there could be some emotional ferocity, because we’re not expecting a miracle here, so the doctor doesn’t feel that they’re a failure if the patient dies. But at least in the ER the expectation is that we’re going to resuscitate somebody, that they don’t send people to the ER to get started on hospice. They send them there because they want us to fix the problem. So if you’re the person who’s going to have to fix the problem, if you fail to fix the problem, your defenses come up pretty quickly. I think that may be human nature, to kind of feel a little defensive that someone said that, or whatever the bad outcome might be that you did your best, but couldn’t forestall the inevitable. So I think most ER people, if you start in the ER all open hearted and caring and being very emotionally involved with everything that happens, those people kind of quit. They tend to get in the way while they’re there, and then they finally quit because it’s just too emotionally painful. Other adaptations can be like cynicism, people can become kind of hard and cynical. Another thing is joking. I joke a lot at work, and sometimes the humor’s cynical and sometimes it’s not cynical. But I think that if you get too well defended, if you had scrubs that are made out of Kevlar and Teflon, which are bullet proof and nothing sticks, it’s hard to drop that when you go home. If you’re too well emotionally intact, if your barriers are up, if you’re defended against the emotional cost of doing the work, when you get home you have a hard time relating to your family, or to your friends, neighbors and stuff. So I think that the more interesting and maybe more pertinent question is how can people that work in high stress environments learn to open up a little bit, close down a little bit, open up a little bit, close down a little bit. So that when they get home they’re not closed down. Even at work they’re not closed down. It sounds like your ER doc was fairly open, right, your ER doc wasn’t some hard ass who came into the room and told you this, told you that and then left. He listened to you. What was your experience like?

Dr. Kent: I remember one thing that was neat for me, it was a specific situation, of course, but he had been a Medic in Vietnam, cause I actually went back and thanked him later on, and this is another question.

Paul Austin: Good for you.

Dr. Kent: That’s the other question, is I felt like this person had changed the course of my father’s life, and I was just sitting in the next room pretty much, with a broken arm. But you do kind of play God sometimes in the ER and some people probably do come back and say thank you.

Paul Austin: Mmm hmm. I even get some thank you notes. But it’s hard to catch us there.

Dr. Kent: Are there certain stories that kind of carry you through the years?

Paul Austin: Yeah, it’s hard to catch an ER doc at work because we work such rotating and crazy shifts. Sometimes we get notes. And most often they’ll bring by some brownies or something to thank the doc or the nurse, and that just means a lot to us.

Dr. Kent: Give us a story of something that happened that you didn’t think you could save someone and something happened, and you know…

Paul Austin: Ok, well here’s a story. This isn’t in the book, but about 8 or 9 years ago I was getting really burned out. I mean, the people who are unhappy are so verbal in the ER. They’ll call the nurse words that you can’t say on the radio. They’ll call me a word you can’t say on the radio. They’ll tell us to hurry up, “Well, hurry up.” I was getting kind of burned out. And there’s a lady came in, the paramedics brought her in. Probably a 75 year old female, she was in respiratory failure, she was just (hacking noise) with respiratory effort, just open mouthed breathing, and she was sweaty, she was pale. They couldn’t get an IV when they brought her in, so they just kind of brought her in and dropped her off and I was going to try to stick a tube in her lungs to get her on the breathing machine so we could figure out what was going on. The nurses were having a hard time getting an IV. You can’t intubate them until you paralyze them. There’s a medicine that we give them that relaxes all the muscles of the body so they can’t fight you when you’re sticking a tube down in their trachea. So I was kind of wishing the nurse would hurry up and get an IV so we could tube, and they got one. We gave her the medicine, and she just went flaccid, so I could stick the tube in her lungs, and I couldn’t get the tube in. Epiglottis is a little trap door that covers up the vocal cords, and she had this big, floppy epiglottis, and I couldn’t get under it. So the pulse ox is going down, the alarms are dinging off. So we put the mask back on her and puffed her back up and then I’m trying to stick that tube in between her vocal chords again and couldn’t see it. And we put the mask back on her face and squeezed that bag to puff air into her lungs. On the third attempt, finally, thanks be to God, I got it. I got the tube in, and by this point I was sweating as much as she was. It was just really uncomfortable. But we got her through, got her on the ventilator, she went off to the intensive care unit, and then I forgot about it. The shift went on and we saw other patients and kept people moving. A couple days later one of the nurses said, “Paul, you know that kind of chunky, white lady you had a hard time tubing?” I said, “Yeah, yeah, what about her?” “Well, she made it out of the unit and she’s on the floor now.” I said, “No kidding?” She said, “Yes, she’s on a regular ward and they’re hoping to let her go home in a couple of days.” She had been in congestive heart failure and we had given her some Lasiks and meds to make her pee, and we got her out of a case of heart failure. Anyway, so I thought I’ll go upstairs and introduce myself, and she will say thank you for saving my life, and then I’ll no longer be burned out. I thought, I have a strategy here. I was working the day shift, so I got off duty and went upstairs. Still had on my scrubs and my tennis shoes, and I went up top two, and I’ll just call her Ms. Smith. I forget her name. I said, “Ms. Smith, I’m Paul Austin. I’m one of the ER doctors, and I’m the one that took care of you when you came into the hospital.” She said, “Who are you?” I said, “I’m Paul Austin, one of the ER doctors. I took care of you in the Emergency Room.” “Are you a paramedic.” I said, “No, no, I’m just a doc.” “Cause those paramedics were so nice.” I said, “Yeah, they were nice, they were really nice. The reason you remember them and you don’t remember me is cause you weren’t conscious by the time you got to me. By the time you got to me your breathing was so bad that you lost consciousness, and I’m the one that put the tube in your windpipe to hook you to a breathing machine so we could get that fluid off your lungs.” She said, “You would not believe how sore that tube made my throat.” (laughter) What do you have to do to get a thank you from this lady? But I said, “I’m sorry it made your throat raw, but I’m glad they could get it out.” And she said, “Well, I guess I should say thank you.” Yeah, just say it, lady, so I can go home. (laughter) And she finally said, “Well, thank you.” I said, “You’re welcome.” But it was so funny. On the elevator back down to the ER locker room to get my stuff, I thought, you know, lady, you have no idea. She was oblivious. There she was, with her little pink nightgown and eating a little powdered doughnuts, little bits of white sugar all over her chest she was kind of brushing off, had no idea of how close she came to dying. I mean, that would have been boom, end game, and move to the next patient. But what I had to do, the nurse was new, and the respiratory therapist was new. I mean, the team knows, we all know when we do a good job, and we all know when we kind of blow it. So you get a lot of, I think most all of us that work there so value their relationships with the folks at work. And one thing I really like about the ER is that the nurses and docs, it’s first name, it’s not Dr. Austin. Some of the new nurses, just right out of the nursing school may say Dr. Austin, but no, just call me Paul, we’re good. And the nurses are real free to come back and say, “Are you sure you mean 10 milligrams.” “Oops, no, you’re right, 1 milligram, you’re right, decimal place.” The nurses are real good about telling me what they think. “Paul, I don’t think she was on a breathing treatment.” “Oh, ok (inaudible).” Where as nurses on the floor and maybe in other specialties, it’s not quite as equal a relationship. But the ER is real democratic kind of place, and a place where pretense and puffiness isn’t tolerated much by the nurses or the docs. We just want to move people through and it’s a great group of people to work with. I used to be a fireman for the city of Highpoint, and it was real similar like the firefighters back then. Now they got one more fire department, which is a good thing. When I was there it was all guys, but the guys at the firehouse, I mean, they believed in putting out fires and pulling people out of the houses. And there’s kind of an innocence to that. And the need, the kind of cynicism and joking and comments about the drunk in Room 2, I think most of the people I work with bring an innocent desire to help people under stress. Sometimes if I’m maybe feeling burnt out, or if I’m working too many night shifts or too many evening shifts, I have to remind myself I get to work with some of the best people I’ve ever known, just on a regular basis.

Dr. Kent: Well it’s a fascinating discussion, and I have a feeling that we could talk for hours. And this book Something For the Pain surely is chock full of these kind of stories. And I’m definitely going to crack my copy. The book is called Something For the Pain, and we’ve been chatting with Paul Austin. Tell us where we can find out more.

Paul Austin: It’s on Amazon. It should be at your local, independent book store. I have a website, paulethanaustin.com, and you can get links to the book, but it’s on Amazon.

Dr. Kent: Absolutely, and the book is Something For the Pain: One Doctor’s Account of Life and Death in the ER. It’s been such a pleasure chatting with you.

Paul Austin: It’s been a pleasure, thanks a lot.

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