Attrition in a Bed of Roses




In our field, we are blessed to see life begin and end, whether in normalcy or chaos. Time is short. You do not know what tomorrow will bring. What is your life? It's even a vapor that appears for a little time and then vanishes away. So why, as clinicians, who should be most connected to this, act like we are so far from it in understanding? Why do we not take advantage of this principle? It is time to find our way out of auto-pilot. What I am going to write about is not a new concept, it seems it is just forgotten and we all need reminded, especially in this time. 


The results of your organization are a direct reflection of the behavior of the people who operate in it. This includes you. How much time, money and energy do we put into everything around us? How much of that do we invest in personal transformation? We are the most complex, confusing, interesting variable. So everything we do must touch on behavior, even down to the hiring process. We will change what we believe just to belong, right? Going against the grain, the self-motivation, it makes you stick out like a sore thumb. This especially occurs in organizations where certain behaviors are tolerated and not remediated or educated to improve. "To educate a man in mind and not in morals is to educate a menace to society."


Don't be average in what you do. Too many good people are average leaders. There is less competition at the top with elite clinicians. If you are in the pile of average, you are in the most competitive arena and there is no chance anyone is going to find you, as an organization or individual. Average feels so safe. Because if I try to become elite I could fail, right? Okay and what, become average again? You go back to the same place you were already in. You are just afraid of being where you are already at. The second you look around and you notice most people look like you and do it like you, that is the first sign you are in the wrong place. If you want your organization to change it starts with the individuals changing, including you. Everybody says, "they need to change." Some people say, "we need to change." Only the elite say, "I need to change." The culture you get is not what you declare for yourself or where you work. It is not a framed quote on the wall. It is discipline and behaviors of each individual. What do we do to change?


It is written of "The Four Loves." All these words in Greek translate to love but all a different meaning. First is Storge. This is a need or gift-type love. Second is Philia. This is a friend or "we" oriented love based on common interests. Third is Eros, a romantic but selfish love based on feeling. Lastly, Agape love. This is others oriented. This is a selfless, sacrificial love. Uncommon commitment. This love drives the individual. To be elite, you need this agape love. This is unconditional love. If you can acquire this, you will do the unthinkable and change the organization you work in. This love is not always fun, it is serious conversation and discipline. It is love that bounds anything from the Navy Seals to a elite college football team. If you don't love where you are at in a job or position, that doesnt make you a bad person. Lift up the hood of the car and see what's the problem. You need to examine where you are at and if after attempting to escape auto-pilot with no changes, don't continue to bring hate, a negative attitude and average to your co-workers and the organization. These negative attributes are like birds, you can't keep them from flying over time to time but you don't have to let them nest in your hair. In this line of work, that is something that others around you and patients do not deserve. 


As a clinician, there will be pain but you will come out better because of it. When adversity and challenges hit, I rejoice because I know the good that will come from it. Stop asking yourself, "why me." Start asking yourself, "what is this teaching me?" "How can I help others from this?" A bed of roses is a beautiful place, but nothing ever develops there. You can be comfortable all you want but you can equate being comfortable to being lifeless. If you ever want to grow, there will be heavy discomfort and sacrifice. We are all, including myself, going to hit that wall of opposition and adversity. I am sure you, like me, have been there many times already as well. Though it is never about what happens to us, it's about how we respond to it. We can control that. If you are resilient you will get what you're looking for and if you are consistent you will keep it. 


In life, we do not burn out because of what we do. We burn out because life makes us forget why we do it. Every single day in whatever you do as a Paramedic, Nurse, Emergency Physician or whatever it may be, ask yourself a question. Dig deep down to your core with conviction and ask yourself why do I really do this? Most importantly, who am I really doing it for? Ego? Pride? Extrinsic reasons? My three whys are on a post-it note on my dash so I am reminded of why I do what I do every day. It reminds me why I sacrifice time to educate myself on subjects that do not involve my schooling. Why I train on topics that are out of my scope of practice. Why I read literature that I may never apply in the field. Why I lose sleep and add stress like most here. Why I sit with books instead of a gaming console. My three whys is what makes me aware that every single day until I take my last breath, I am going to spend training mentally and physically, study and educate to impact others lives in what I do in and out of the job and give them the best possible chance. Even if that just means holding their hand. What is your why?  




The Haunting: Foregoing our Faults


No one in emergency medicine wakes up in the morning and plans on going out of their way to make errors in patient care. We strive for perfection when treating our patients, at least most of us. We make clinical decisions to the best of our ability from what we have accrued in education, what resources we have at our disposal and what mistakes we have learned from time and experience in our careers.  

When I began my career as a paramedic, I unfortunately took everything I heard from instructors, command staff and others opinions and ideology towards other clinicians. I let it infect me. I mean, they were my mentors, peers and experienced clinicians I had looked up to. Why not ingest everything they tell me?  “So practice and observe everything they tell you. But do not do what they do. For they do not practice what they preach." Man, I wish I would have applied that earlier in my career but we live and learn right? 

Until I began to progress into a position of leadership, as well as beginning to gain influence from great mentors in and outside of the job, did I realize that these traits were not improving our organization or the organizations around us. Unfortunately, it was beginning to become a part of my personality. Absolutely shameful as I look back and see the kind of conversation I became a part of to make our organization appear better than the ones surrounding us.

There were resentful and judgemental opinions toward others involved in patient care in outside facilities, volunteer and other pre-hospital organizations. This became a part of a culture. Working at the hospital, how many times has someone transferred care to your facility and given the report en route or at bedside and you or someone else says “oh, its insert flight program here” or “of course, its insert EMS organization here." Even when EMS arrives at nursing facilities, "how much do you want to bet this patient is in septic shock." Why not help them? Why not educate them? Why not attempt to see where they are coming from? As a clinician, if you have more education with the matter at hand, why not reach out and provide it for them? When we get back to base, station or stock the trauma bay for the next patient, where is our own post-incident review? I am not talking a debrief of “well it went well with what we had." Please stop saying this. I cringe every time I hear that statement. No questions? No criticism of our own care? Why? Well, we are the best to do it, right? Even if we did make any mistakes, why would we open them up to others and let everyone know our imperfections of care, realizing there is room for improvement of our own performance, policies and guidelines. This is a perfect example of a teachable moment. 




After all of this, when we transfer the patient to the next level of care, we clock out and go home. The possibility of discussing, correcting and managing future errors in care dissipates when we lay our head down at night, never to be spoken of or heard again. Atleast until these faults of ourself and others come back to haunt us. The circle of animosity and not educating others or ourselves continues into the next shift to repeat itself over and over and over again. We are all guilty. Whether it is out of pure frustration, lack of sleep or repeated instances. 


This develops into a constant framework of vindication, unwillingness to expose our own failures and the inability to educate ourselves and those around us who might have made any errors involved in the process of patient care. What are we teaching our new employees and students? Even clinicians outside of our organization who were wanting an opportunity of employment with us but now see our ego and remarks. This occurs quite often in organizations with anyone above or below them in size, education and performance. No one is without sin.  


Society overall has a negative outlook on failure and mistakes in general, especially when it applies to the setting of patient care. This begins with certain clinicians within the organization and leadership permitting their behavior, if not themselves, to float along like that particle of dust in your attic when you turn the light on watching it settle on others. They lack self-reflection and humility and don't take the steps necessary to correct errors surrounding patient care. 



I find it funny how much of an impact working in a negative environment can give you such humility and further character, as long as you are self aware of the environment you are in. I am personally grateful for that experience. Where as an organization that is doing things correctly, at least most the time, I can’t say you would acquire certain traits and mentality. It is fairly easy to drift through a high-caliber work environment without constant negativity and conflict and not read between the lines. Though, when things are not going well in a constantly negative environment, you acquire how not to manage people, how not to build character, how not to prioritize, how not to communicate and the list goes on. When things are going right, it is hard to notice and acquire the attributes at times that are meant to achieve overall organizational success. You usually will not go out of your way to say “things are so fluent and operable here, what can I improve?”. No, most of the time, you start asking questions when you and the others around you are digging yourself out of a hole, asking how the hell did we get to this point and where do we go from here? 


We don’t wake up one day and become an attending at an emergency department or a respiratory therapist with 10 years experience, or even a flight paramedic/nurse with a major flight program. Not every hospital, HEMS or EMS organization has the same resources, same patient contact or same education. Remember where you came from and realize that every moment of failure or wrong approach can be educational. You are doing nothing to improve the outcome of patient care or improving others by constantly belittling but offering no solution for the next patient. Remember, they are calling you. They are transferring the patient to you. They want help. They need help. Offer help and advice. Don't be condescending. 


As someone with any influence in any organization, in any position, become that “elite” clinician who helps initiate this culture of understanding and attempts to first use these moments in care as a learning opportunity instead of making our employees or outside personnel terrified at the possibility of embarrassment or discipline. At the end of the day, we are here for the patient, no? Give our future patients the best care possible and withdraw the possibility of that same error returning to haunt us and those around us.


Failure is inevitable. What will you do as an individual or organization, to create a culture without animosity and the ability to learn from yourself and others?  It starts with a choice. Be the change you want to see the next time you walk through that door.  




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