It’s 6:30 in the morning.  I’ve just gotten to work.  I haven’t even put my bag down yet.  The knit wool beanie my wife made for me 11 years ago still keeps my head warm when an ambulance rings us down on the radio with incoming traffic.   The medics are transporting a mid 50’s male with a report of heavy ETOH (That’s alcohol) and they inform us the pt is very familiar to us.  

Take a deep breath

No sign of injury, they continue.  No complaints from the patient.  But he is difficult to assess due to the ETOH.   He is slurring his words and has been incontinent of urine.  There was an empty vodka bottle on the ground next to him.  He is being verbally abusive, but not physically combative…

I should put my things down and get a room ready.

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Next patient: a baby with a fever presents in the lobby.  She has been up crying on and off the whole night.  She has a runny nose and is teething.  Her eyes are red and puffy.  Her young parents haven’t slept.  This is the first time she has been sick.  They are full of Love for her but have no idea what constitutes Big sick vs Little sick and have no clue what to do.  Not their fault.  No-one teaches this stuff.  Maybe I can take the opportunity to begin a little education while they’re here …

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“Michael, your other patient is urinating on the floor and it looks like he’s going ot fall out of bed!”  It’s true.  The guy is kneeling, leaning against the bed rails and relieving himself onto the floor.  He does look likely to topple onto his head.

I swear because I care.

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This exact scenario hasn’t played out word for word (Or maybe it has).   This is the kind of thing that can happen though.   This is a job that produces unavoidable interactions with other people.  Interactions I would never have under any other circumstances.  I don’t control who I will be interacting with.  Or When.  Or how they’ll treat me.  Or who else will be there enacting their own behavior at the same time.  I guess a lot of jobs have this in common.  I’m going to guess though that on the social, behavioral, functional continuum of individuals the difference between interactions one relishes and those one shuns stretches quite a bit wider in the ED than in most other workplaces.  That’s the premise I’m going with for this piece anyway.

It doesn’t take too much imagination to envision situations where a person in such a position will be in wildly different interactions at the same time, each with its own demands and challenges and requiring deployment of wide ranging, sometimes even opposite behaviors on my part in order to provide the appropriate” care” for each patient.  Each patient needs something different.  That brings me to the thing I do have control of.  That is how I will interact with each patient and family I come in contact with.  

Let me tell you it is not easy.   And after twenty years in the ER I still have a lot of room for improvement.  To that degree I have grown better at it, I owe thanks to my wife Cecile whose loving example has osmotically transferred some useful tools to me over time.  Through her steady and compassionate nature and her genuinely held belief that Love is why we are here I have been able to expand my capacity for compassion.  (A smidge)
Ideally I would be able to bring my same self to each interaction and have something of myself to give.  Doesn’t that sound awesome!  I would leave work every day feeling amazing if I could have meaningful engagement with each and every person I dealt with! 

But I can’t.

I have to know where to set the aperture for my heart and soul for each situation.  Sometimes a wide open setting is called for to provide the touch that will provide a spark and Healing will happen. When it does it’s sweet and the feeling can sustain you.   Maybe it’s just taking a little extra time listening when someone really needs that.  Maybe it’s just showing basic respect to a person who never sees it from others.  Maybe it’s sharing some of my own parenting journey with scared new first time parents and letting them know it will be alright in the end.   Opening up to the other person on a basic level can create a space where everyone walks away feeling good.

But

 Sometimes a total lockdown is required to protect myself from the damaging effects that could be inflicted on me if I let the wrong person too close in.  Usually it’s somewhere in between.  Make the wrong choice either direction and the things can get bad.  Fast.  I can, and have unintentionally hurt people’s feelings and angered them through slight misjudgment on my part.  Sometimes someone who really does need some help will abruptly bolt and I may not even know what triggered them.    I have been knocked out of my chair with a punch to the jaw I didn’t see coming when I let the wrong person get outside the field of my peripheral vision.  I have been yelled at, spit at, treated to sublime profanity and wretched propositions by men and women, young and old.  People have said they would kill me.  Over and over and over, but I think I’m still alive.  

 It doesn’t pay to be a perfectionist about this.  But I sometimes forget.  It is easy to fall into a trap of thinking I should have known how things would go.  It would be cool if I could just nail this!  If I could just snap judge it, Bam!  And get it just right.  Yeah.  That would make things a lot easier in the emotional dance we do with our patients.  I could be a better nurse.  I could be more balanced when I get home.

When I get home…  Oh my, I have 40 minutes of driving time to transform myself from the hardened gritty shit magnet or tattered soggy dishrag I have turned into emotionally, through the crucible of my 12 hour shift, into some semblance of an appropriate family man.  I use that drive as my phone booth to change, to shuck off the things my family never needs to know and deposit them somewhere.  I have to do this in order to be the person who is going to interact with a wife and three children who don’t inhabit the world of the ER.  If I don’t something will slip or bubble out in an awful way and everything will go silent and still and I will know.  Know that my costume change has not been complete and Nurse Michael is still not quite ready for listening and reacting to Kindergarten stories.  Nurse Michael is not quite equipped to help with high school homework or to show proper sensitivity when hearing about the difficulties of a Loved One’s day, which though valid, pale by comparison to what I have just slogged through.  Sometimes that 40 minute drive is not quite long enough to leave it all behind.

Sometimes though, on the drive I will try to remember each patient I interacted with during the day.  I want to be able to remember, so I can process things, or write about something funny, or reinforce the memory of something that went right so I can do it that way again.  But most daze it feels like trying to pull something whole out of a blender.  All the distinction of each individual interaction has been homogenized into a grey slurry and I can’t seem to access any of it. 

Usually though I can remember and continue to feel whether I had to be Open or Closed to do my job, and whether or not it had worked.