Physician and Nurse Burn – Out – Part XX. Mistakes in Children’s Medications

– “For a nurse, nothing compares to a screw-up in a kid’s medication —period.”

Louise X. is a veteran and proficient nurse that works in the Oncology ward of a large South Florida public hospital, who almost harmed an admitted child when she wrongly calculated the dilution parameters of a medication that comes in adult dosage from the manufacturer and must be adapted to lower children’s dosages. It was early dawn, and she was about to finish her nightly shift with a last round of medications for the admitted patients. The fatal error could have hurt the patient but providentially there is a protocol of double check up of these dosages in her hospital. An on-duty pharmacist picked up the mistake and quickly called her to correct it.

Note. This reproduction of a World War II US Army’s recruiting poster was taken from Wikimedia Commons.

Medication errors are frequent in all medical institutions worldwide. The National Coordinating Council for Medication Error Reporting and Prevention defines them as: “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education, monitoring; and use.” Traditionally Nursing Schools have taught their students to follow the Five Rights rule in their practices:

  1. Right patient.
  2. Right Drug.
  3. Right dose.
  4. Right route.
  5. Right Time.

Some reviews claim medical errors in the USA range from less than 0.2% to a whooping 10% of all prescriptions, which is difficult to determine due to under or wrong reporting; a serious study across the whole health care spectrum is needed.

Not only the nursing personnel that administers the medication is to blame but we, physicians, have a fair share of blame as we should avoid these common mistakes:

  1. We should avoid the use of confusing symbols like “U” and write the full name “Units” instead.
  2. We should avoid the abbreviations and acronyms and write the full name.
  3. We should not determine the frequency with complex signs like QD. QOD or QID, but rather spell it clearly with common vocabulary.
  4. We should not use zeros before or after a number.
  5. We should not use any abbreviations for the medications’

There should be sound prescribing policies in al major health care institutions like:

  1. Drug reference material should be available online to care personnel.
  2. Basic clinical information like age, weight, allergies, etc., should be clear.
  3. If a physician’s order is unclear, incomplete, or illegible, it should be clarified.
  4. Dispense single-dose vials and ampules, avoiding multidose vials.
  5. Whenever possible, prefer oral administration rather than parenteral routes.
  6. Avoid distracting activities like texting when you do the medication rounds.
  7. Oblige a second pharmacist to doublecheck all the dangerous medications.
  8. Be aware of look-alike or sound-like medications when you are dispensing.

Pediatric patients are especially vulnerable to any medication errors as a) they cannot clearly communicate any discomfort and b) their physiology is still immature, with the renal and hepatic clearing systems still in their early stages of operation. That is why this nurse felt that she could have harmed the child with that excessive dosage.

There is also a big factor that crosses all the segments and specialties of Health Care. There is widespread tiredness and disillusionment in our files as the persistent micromanagement of payors, the still excessive paperwork despite the widespread use of electronic medical records, the offensive demeaning of professional roles by the encroaching of management and bureaucrats, the need for constant updates, etc., has been sapping our enthusiasm, notwithstanding our strong medical vocations.

One veteran professor in our Medical School warned us, the rookies, as follows:

“Hay que dejar la medicina antes que la medicina te deje.”

(You must leave medicine before it leaves you)

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn-Out – Part XIX. Suicide of a Patient

Occasionally you wish you were wrong, even if you knew you were not.

That is how we felt when, working in a Neurology Residency in a large New York City hospital, we went back to its Psychiatric Inpatient Unit (we are withholding the details for privacy reasons) for a follow-up on a patient that we had diagnosed with Migraines and started treating him, just some days earlier. In our first contact with him, aside from that neurological diagnosis, we noticed that he was in a heightened state of Anxiety/ Depression that seemed not to respond to his medication schedule. Before leaving the ward, we summoned his treating resident to recommend a Suicide Watch.

The pompous “Jersey Boy”—in charge of his clinical care—duly listened to us with a disgusting smirk on his face and then said: “thank you for your concern but you’re wrong. He is well medicated. Do us a favor. You treat his Migraines, and we’ll take care of the Psychiatric end. Agree?” In an utterly condescending gesture, he patted us on the back.

We kept mum as we did not want to engage in a quarrel with another resident that was more senior than we were; but we did observe the golden rule we had learned right at the start of our internship. CWA ( it means “cover your a**) We clearly wrote our fact-based recommendation in our Consultation sheet to comply with that maxim. When we returned to that ward there was a big commotion. As the treating team was duped into believing that this patient “was better off,” he was assigned as a kitchen helper for the next Thanksgiving dinner. And “the inevitable” happened.

When nobody was around, he improvised a noose with linen cloths in a pantry room, quickly threw it around a ceiling’s wood rafter, put it around his neck, got up on a chair and then jumped out, hanging himself. On our way to the ward, everybody was looking at us in total amazement. No, we were not a soothsayer, nor did we engage in crystal ball’s reading. We used our hard-earned medical knowledge and clinical criteria to diagnose “the obvious intentions” of a sick individual. Even if we flatly denied it, some colleagues (especially the ladies) were whispering behind our back that we in fact possessed “a secret gift.” It never hurts to impress the ladies…

Note. This reproduction of a World War II US Navy’s recruiting poster was taken from Wikimedia Commons.

There are 50-65 suicides of hospitalized patients in the USA, usually by hanging and less frequently by the ingestion of toxic substances, which is more common in the rare instance when a female patient is involved; they usually occur in the Psychiatry Units of large public or private hospitals, less frequently in better supervised private clinics or rehabilitation institutions. The Joint Commission has recommended the following Suicide Prevention strategies for clinicians:

  1. Review the patient’s clinical records and family history for risk factors.
  2. Screen all patients for suicide ideation using a standardized test.
  3. Review the patients’ answers before he/she leaves the office or is discharged.
  4. Engage the family members and other treating physicians for better results.
  5. Prepare admission and discharge protocols that specifically address this risk.
  6. Train all the members of the clinical team to look out for signs of this risk.
  7. Document all the decisions that were made to address this critical risk factor.

However, one of the most common clinical traps we can fall into is what we have described in Emotional Frustration – the Hushed Plague as follows:

“One of the most disseminated fallacies is that someone that attempts suicide must be in a manifest state of anxiety, depression, and despair. A misleading assumption. Many patients are clinically depressed but only a minority has suicidal ideation; similarly, some with suicidal thoughts never have signs of a major depression.

Moreover, when they decide to act, they reach a state of tranquility—akin to a Buddhist peace of mind. Depression is not synonymous with Suicide.”

We, health care providers, have a sacred duty to spot and treat these patients.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn Out – Part XVIII. Medical Errors.

– “Doctor…Can’t take this s*** anymore…I am heading for the exit door—You should do the same.”

Sheila X. is a proficient Critical Care nurse that, after a medical error she committed in a medication schedule that was providentially spotted by her supervisor, decided that her work stress was too much, especially after toiling so hard in the pandemic. She could opt for an early retirement, with a nice monthly check and benefits; she did not want to risk those benefits for the sake of a few more months of work. It was time for her to quit a career she has always loved. She stopped being sentimental like so many of us still are.

In a 1999 Institute of Medicine’s publication titled To Err is Human, Building a Safer Health System, investigators found an alarming rate of medical errors in the USA, which could be at least 44.000 incidents per year, even reaching the astounding number of up to 98.000 deaths of admitted patients in hospitals and clinics. We must assume that for each incident, there might be at least one, two, three, even more nurses, technicians and physicians involved, with varying degrees of responsibility. Medical Errors could represent the third leading cause of deaths in the USA.

Note. This World War II US Navy’s recruiting poster was taken form Wikimedia Commons. At that time Women were not allowed to serve in any frontline combat positions and had to staff the auxiliary sections of the Marine Corps. That sounds so, so retrogradely condescending now. As the famous Virginia Slims poster said; “You’ve come a long way Baby.”

The IOM Committee on Quality of Healthcare in the USA stated that a Medical Error is “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” We must clarify that a priori a medical error does not imply that there has been an intentional act to commit harm to a patient or an act of medical malpractice. There are two major types of Medical Errors defined as follows:

  1. Error of Execution: the planned action does not proceed as it was intended.
  2. Error of Planning: the originally intended action was poorly designed.

Not all medical errors reach the grave status of a “sentinel incident” that must be reported to the hospital authorities and the regulating agencies for professionals. If there is a common complication like a wound infection after a major procedure, professionals must evaluate whether it was totally preventable if a mistake would not have been committed, or it was simply a complication that could not be avoided.

The Joint Committee, a national organization charged with studying Medical Errors, defined a sentinel event as “an unexpected occurrence involving the death of or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.” They proposed using the root case analysis to identify “the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.”

There are two major types of sentinel events as follows:

I – Death of the patient or a serious permanent loss of function, not associated with the expected clinical course of the pathological condition or co-morbidity.

II – It involves one or two of the following medical conditions, which do not attain the seriousness of death or loss of a major bodily functions. They are:

  1. Suicide of an admitted patient.
  2. Unexpected death of a full-term infant.
  3. Abduction of an admitted patient.
  4. Assignment of the wrong infant to a family.
  5. Rape, battery, or assault of an admitted patient.
  6. Rape, battery, or assault of a Staff member.
  7. Administration of incompatible blood products.
  8. Post-operative retention of a Foreign Object.
  9. Severe Neonatal Hyperbilirubinemia.
  10. Prolonged Fluoroscopy with Excessive Radiation dosage.
  11. Maternal morbidity or mortality.
  12. Fire hazard.

In a series of articles, we will discuss the major types of Medical Errors and how they profoundly affect the treating personnel, not only because they might have been involved in such an instance, but also because they might be genuinely concerned that it might occur to them. Only well trained and hypervigilant professionals avoid the risk of any of them.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn-out – Part XVII. Post-Pandemic Blues

After all the previous pandemics that affected Humankind, there has always been a trove of physical and mental health sequelae for the involved caregivers. But the COVID-19 pandemic has  been especially taxing for the nurses, physicians, technicians, auxiliary personnel, etc., of the treating health care institutions. Now that the pandemic seems to be easing off, or at least become an endemic process, the Public Health and Health Care administration experts are reviewing the data and comparing it to previous pandemics and their aftermath. Rachel Schwartz reviewed 97 articles addressing the clinical mental health problems in COVID 19 and other pandemics. They found 7 major themes:

  1. Need for resilience and stress reduction training
  2. Provide clinicians’ basic needs (food, drink, adequate rest, quarantine-appropriate housing, transportation, childcare, personal protective gear)
  3. Importance of specialized training for pandemic-induced changes in job roles.
  4. Recognition and clear communication from leadership.
  5. Acknowledgement of and strategies for addressing moral injury.
  6. The need for peer and special support interventions.
  7. Normalization and provision of mental health support programs.

The authors emphasize that administrative cadres in health care institutions must take a pro-active support of physicians and nurses as they are known to be very reluctant to seek clinical support on time and they usually relegate their own needs.

Note. This US Navy recruiting poster from World War II was taken from Wikimedia Commons.

In an American Medical Association (AMA) news release, Jennifer Lubell informed us: “Fallout from Hurricane Ida and the COVID-19 pandemic led to the high levels of burnout and post-traumatic stress disorders among employees if Ochsner Health. But help is on the way. Armed with 2.9 million in federal funds, the large Louisiana-based health system plans to breathe new life into its workforce through seven evidence-based wellness programs.” They are:

  1. Johnson and Johnson Resilience Training: aims to protect mental and physical health of employees and deliver good health outcomes.
  2. Personal Leadership Program: aims to support senior leaders, physicians, nonphysicians clinicians in their professional advancement initiatives.
  3. Peer Resilience Program: supports those promising employees with well-defined practical protocols that they can use to face adverse situations.
  4. Institute for HealthCare Improvement: this program is especially directed at nursing personnel, and we discussed it in our article about Nurse Turn-Over.
  5. Cabana by Even Health: it allows staff to share challenges, successes, and strategies for addressing health care providers’ concerns.
  6. Schwartz Rounds: allows professionals to have regularly scheduled times to discuss critical issues in their organizations.
  7. Employee Assistance Programs: include departments where issues ranging from labor, family, financial, drug addiction and alcohol, divorce, etc. are discussed to help the employees.

One of the most contentious issues in the care of professional cadres is their aversion to reveal their mental health problems to colleagues and superiors alike for fear of “some social censure” or its impact in their advancement prospects. For that reason, the Cabana project has the possibility for concerned individuals to create an avatar that would mask their identities while they are participating in group therapy under the direction of a licensed behavioral health specialist.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn-Out – Part XVI – Nursing Turn-Over

“If they believe they can sweet-talk us with just a few bucks—they got it coming.”

Norma X. is a very qualified and smart Critical Care nurse that has been seriously considering retiring from the profession after more than twenty years off service due to the physical and mental exhaustion after two long years of pandemic. Management is desperate to keep her, not only to continue taking care of seriously ill patients, but also to guide the young nurses that seem to be entering the career with less knowledge and experience than before to meet the increasing demand. She scoffs at the array of perks they try to entice her with to sign another contract. She confessed to us that she is only dreaming of her retirement in easy Key West with her hubby and two dogs (their grandchildren can visit them but only once a year)

All health care providers know that nursing personnel is the main pillar of a modern Health Care Delivery system, usually more important than the medical corps itself. Most public and private delivery organizations have the strategic imperative of retaining them, and what is more important, to keep them happy in their careers. After the 2008 recession, rates of  unemployment rose in all the economy sectors and some experienced nurses delayed their retirement to account for an increased living cost. At that time retention of nursing personnel was not a problem and institutions were not hiring the new graduates. Now the tide has turned as the new clinical demands of a protracted COVID-19 pandemic has strained the human resources of many hospitals and clinics in the USA. Newly graduated nurses are in high demand but that brings new operational challenges to policymakers and administrators.

Training qualified nursing personnel is very expensive, approximately amounting to double their yearly salaries; institutions cannot afford to have a normal 2-3% staff turnover without suffering the consequences. Their four main reasons to quit are:

  1. Excessive patient workload, worsened during the pandemic,
  2. No scheduling flexibility to accommodate the family life obligations.
  3. Sub-par financial compensation that stresses their family budgets.
  4. Professional frustration due to the lack of continuing education possibilities to advance their careers inside their institutions.

As the exodus rises, the remining nurses inherit heavier workloads, which in turn entices them to follow their colleagues to the exit doors, and so on. A vicious circle. Moreover now large institutions, desperate to cover their many vacancies, are hiring increasingly younger graduates, who have the highest attrition rate in the first year. To meet the market increased demand for nurses, their licensing requirements have been streamlined and the novel nurses get their badges much earlier than before. The rookies are increasingly being deployed in highly critical areas where there is a lot of stress and require clinical knowledge and expertise that they do not yet possess.

Note. This World War II Navy recruiting poster was taken from Wikimedia Commons.

These novel nurses must be paired with an experienced nurse providing emotional support and clinical expertise to the newly entrants; checking on them in a regular basis and simply by “being there for them” will boost the morale of young recruits. Now these “support role” has been systematically developed into protocols by the American Associates of Colleges of Nursing that established the Vizient/AACN Nurse Residency Program to support the entry-level nurses as they transition into clinical practice. The evidence-based curriculum focuses on three critical areas:

a) Leadership Skills and Pathways.

b) Patients’ Good Outcomes.

c) Continuous Professional Development.

A not-so-well-kept-secret-of-the-caring-professions is the mendacious role played by some old-timers in the nursing profession that systematically harass and demean the rookies, perhaps trying to make them pay for “sins” committed by physicians, in a classical example of what Sigmund Freud described as a displacement mechanism that we fully discuss in our new book Emotional Frustration – the Hushed Plague. The horizontal abuse of colleagues must stop, and senior staff must be vigilant. Because most of these recent nursing graduates are young ladies a little bit too shy for their own good, who prefer to quit their jobs in silence rather than complain. The formal mechanisms to report labor abuse must be operational and easy to access.

Of course the salaries and perks of Nursing personnel must be raised to make them closer to what physicians actually earn in the public and private institutions. But more importantly the feminization of the Health Care workforce has given new impetus to the longstanding demand of nurses that management should consider the family life of their employees by offering more flexible scheduling and coverage. Promoting a healthy, inclusive, respectful environment will certainly impress nurses.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.


Physician and Nurse Burn-out – Part XV Group Therapy

-“We are watching so much horror —and we must take it with a stiff upper lip?”

That complaint from one of our medical colleagues recently summarizes the sorry spiritual state of most of the health care practitioners that have been taking care of very sick patients in all these interminable months of the COVID 19-pandemic. Most of us are physically exhausted and emotionally depleted with no relief in sight. There are manifold signs that as the non-stop clinical burden takes a heavy tool on us, many are experiencing serious signs of stress overload and emotional/ mental surmenage.

In a great paper, Dr. Clare Gerada stated that the same personality traits that allow us physicians to bear so many clinical responsibilities in grueling work schedules are the same ones that might predispose us to sickness and prevent us from seeking specialized help early on in the process. According to Gwen Adshead, we are:

  1. Perfectionists
  2. Narcissists
  3. Compulsives
  4. Denigrators of Vulnerability
  5. Martyrs

Most physicians can easily recognize a few or all of these traits in our personalities because we have a good esprit de corps that makes us feel “different from others.” We all have a deep-rooted sense of “being special” and our professional identity gets consolidated as we plow through the study-intensive Medical School and the ridiculously demanding work schedules of Post-Graduate Training. It is our armor for survival. In fact all our personal lives get subsumed by the demands of clinical work and the hospital demands replace the ones from family and home; akin to a secret cult we create our own jargon and a new way to see things: the medical gaze.

When we physicians get sick there are external and internal defense mechanisms that usually make us hide the reality and waste precious time to get the needed professional help. You got sick? How come? It can’t be. We , doctors, do not get sick. The others do… Moreover, in all these long months of  pandemic horror and the associated Social Isolation prodded us to necessarily acquire two tricky psychological defense mechanisms: depersonalization and denial of feelings. In order for us to slog through our tasks and still remain operational, we had to “take distance” from the encroaching Death and Despair. The farther apart we moved form the daily horror, the more we duped ourselves into believing that we were somehow “invincible”, which is usually a hallmark of the younger Docs. As we are now used to work in clinical groups with different specialties,  we tend to abhor the idea of “being sick ourselves” as it is like a treason to our healer’s oath to always be ready for big service.  Moreover, if we get sick, someone else will have to pick up the slack with our patients.

Note. Considering that our two references are British authors, we decided to put as featured image this Royal Navy World War II recruiting poster, which was taken from Wikimedia Commons.

Humans need to live in groups and feel a “sense of belonging” to feel fine. For us physicians the primary belonging is to our clinical work and when it is destroyed, then we need a secondary group, preferably with the company of our peers. In another great article, Dr. Gerada discusses the NHS Practitioner Health Program,  which is a very confidential service to discuss and treat the Mental Health disorders of physicians. Finally freed from their masks of empathy, health care practitioners can “spill the beans” in the comforting company of their peers sharing their angst. In the 2008 sample she studied at the time she found that three fourth of cases had Depression/ Anxiety and only a fourth had Substance Abuse problems. She claimed that this represented only a stopover solution and that eventually most of them responded to psychological therapies and later joined other non-medical groups. As the exclusivity of physicians’ privileges have been steadily contested by a more egalitarian approach to health delivery services, there are hardly any physicians’ meeting points like reading and discussion lounges, lunch spaces, etc. We lost the intimate contact with our peers.

She wrote: “it is important that, as health professionals, we engage as patients, participants, and as providers in group work. Part of any strategy to improve retention of doctors must involve creating spaces for doctors to reflect together, support each other and share techniques for remaining mentally healthy.”

In order to get some well-deserved relief from the stress and angst we suffer now, we. physicians, must first take the step of getting rid of our guild-identifying lab coats. Below them, we are simple human beings, notwithstanding all our knowledge. In the re-assuring company of colleagues, including nurses, and devoid of our silly theatrics pour la gallery, we can finally begin to heal.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.

Physician and Nurse Burn-out. Part XIV – Wearing Two Hats

What do physicians and nurses have in common with Canadian truckers? Plenty.

Rous Dhouhat, Opinion writer of The New York Times, wrote an article where he explained how the much-vaunted meritocratic system of our modern societies has degenerated into a binary caste system dividing us in two separate camps. He wrote: “A great and mostly unknown prophet of our times Michael Young, whose book ‘The Rise of the Meritocracy’, published back in 1958, both coined the term in its title and predicted, in its fictional vision of the 21st century, meritocracy’s unhappy destination: not the severe rue of the deserving and talented, but a society where a ruling class selected for intelligence but defined by arrogance and insularity faces a railing populism where grievances shift but whose anger at the new class order is constant.”

Michael Dunlop Young, British sociologist and politician, coined the term meritocracy by fusing the Lain verb “mereor” or “demereor”, which means “to deserve”, and the Greek suffix “cracy”. He was in fact ridiculing a planned transformation of the Educational System in the United Kingdom, which destroyed the traditionally egalitarian role of  their Public System by creating a schism in society at large. He rightly foretold that intelligence and merit would become the central pillars of the new British society, replacing the traditional class warfare envisioned by Karl Marx. He predicted that on one hand, there would be a merited, powerful intellectual mandarinate and on the other hand a less merited, alienated lumpen proletariat. His manuscript was roundly rejected by 11 publishers until Thames and Hudson agreed to publish it.

After this terrible pandemic, there has been a stark differentiation between those that gawk at the symbols in a screen all day long and those that use their hands to work. Young wrote his book before the advent of the computer and could not have fathomed the extent of his visionary conception of the world we are now living. Watching the rebellious truckers’ protests in Canada, N.S. Lyons alerted about the clash between those that work by manipulating data and those that have daily contact with the physical world. He divided workers into The Virtuals and The Practicals.

Note. This image of a First World War Navy recruiting poster was taken from Wikimedia Commons.

What does all the above have to do with our daily tasks as physicians and nurses? Fortunately, most of us are working in a hybrid environment where we have daily physical contact with our patients with their raw realities but at the same time, we sit for hours on end in front of computer screens to gawk at the Electronic Medical Records (EMR) to decide on virtual pathways that only exist in the digital world. As a result we receive the input of both worlds and share their unique challenges.

In this challenging Post-Pandemic World, physicians and nurses must daily juggle the obligations of wearing two hats. The Mandarin’s button spheres that separates us from commoners. And the Proletariat’s flat cloth cap that gets us closer to them.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.



Physician and Nurse Burn-out . Part XIII  – Split Second Decisions.

Where lies the oversized professional and social power of, us, physicians?

Financial recourses? No. Political power? No. Social Influencing? No.

It resides in the fact that we can make split-second Life or Death decisions.

When we were doing our internship in a large New York City hospital, we had to do a 24 hours-On Call stint every three days, which meant that we spent a large amount of time in the facility, working side by side with dozens of residents from across all the specialties and training levels. When our duty was done, we liked to meet in the large On Call room to have a snack and watch TV together. Yes, those were the times when we all participated in the same viewing. No nasty arguments.

One day I showed up with a tuna sandwich and saw a black and white TV program where there was a smiling fat bus driver fighting with his blonde wife in their living room.

-“Mario,” Steve, a fellow intern said to me, “have you ever watched this program?”

-“No, “ I replied. “What is it?”

-“The Honeymooners. Sit down. You’ll love it, buddy.”

From that moment on we got hooked on the funny episodes of a sitcom featuring ralph and his wife Alice, which had made its debut in 1951, before we were born. It was comforting to share a meal and distraction with other Young Turks…Until.

-“CODE BLEU IN THE ICU,” the loudspeakers blared. And all our beepers (small digital devices that we had to carry with us, even to the bathroom) started ringing.

We all dropped whatever we had in our hands and stampeded out to the exit door. There was no time to wait for the elevators , so we ran up the stairs to the third floor where the ICU was located. Usually there were other interns and residents already there, working on the Cardio-Pulmonary Resuscitation of the compromised patient.

However, we all just stood in silence, waiting for any instructions or orders. Just like in the Military. Once the loudspeakers called the Code off (either because the patient had survived or , much more commonly, because he/she had died) we all left.

This drill was repeated once or twice every time we were On Call. Again. And again…Until one day what we , the rookies, secretly dreaded did happen….When we arrived at the ICU or the wardroom where the Code was called for, we were met by the Head Nurse, who summarily told us: “Get ready. The nurse started. Go.”

We were ushered into the room where the nurse was pumping oxygen into the patient’s mouth with an Ambou bag; another one was trying to get an intravenous line. Often the anesthesiologist On Call was there, getting ready to intubate the patient. But on that occasion, he was busy in an emergency surgery in the operating room; we, the interns, or residents, had to intubate the patient. No delay.

Note. This image of a World War II poster for Nurse recruitment  in the Navy was taken from

The first time a nurse handed us the intubation kit, we almost fainted to the floor. We managed to grab it and we went behind the patient’s back. We opened his mouth; we slid the apparatus down the left side of his mouth and then pulled our hard upwards. The first orifice that you see belongs to the  Digestive tract. You have to pull the handle up to see another orifice, exactly in front of the other one, belonging to the Respiratory tract. We slid the previously lubricated tube in a diagonally upwards direction. We asked the nurse to check the positioning of the tube. “Good. Doctor.”

Before we came to the USA to do our Post Graduate training, we worked for two years at two small countryside hospitals in Buenos Aires province, where we usually covered all the Emergencies for the whole weekend, assisted by the attending physicians. They often responded but sometimes, they were MIA; it usually occurred when the philandering docs put the excuse of “I am On Call” to their wives in order to meet their lovers  in a love shack by the Riverside. We kept mum.

One night we had just taken the On Call service in the public hospital in San Miguel del Monte and their top clinician stopped by at dinnertime to duly warn me:

-“Hey, my new sweetheart wants to see a play in La Plata, and we are leaving now.”

-“La Plata?” we shot back. “”That is almost one hour away in the fastest car!”

-“Don’t worry, you are doing fine here with us. When we’re back, I’ll stop by…”

A little anxious, we nonetheless made the final rounds and went to bed at midnight.

At 2 AM, the Chief Nurse barged into our On Call room and turned the lights on.

-“Doctor, Mrs. X came to the ER…She’s due in these days…Hurry up.”

Of course she was referring to a term pregnancy attended by the Lothario.

The nurse escorted us to the Obstetrics section of the ER where a young woman was already in the exam chair with her legs wide open. Next to her stood the anesthesiologist who was slowly dripping some pain medication into her spine and the midwife, ready to take care of the newborn.


-“Hurry Doctor, the baby wants to come out…Here, give your hand and I’ll show you, ” she said before taking over the motricity of our two Upper Extremities to go through the motions. She handed us the cutting knife and took a big piece of the patient’s vulva. “Cut here, “ she said showing us how to do an Episiotomy.

-“Push, push,” the midwife ordered. Exhausted, the patient made a last muscular effort. And in a few seconds, we could grab the amniotic fluid- covered head of a boy. With her help, we could deliver a healthy boy and we gave him to the mother so she could feel him; the midwife cleared his nostrils and enveloped him with a blanket.

-“What’s his name?” I asked the mother.

-“Federico,” she replied.

Smiling with pride, we went back to our On Call room to write a letter to our dear grandmother Yolanda in Montevideo, to tell her the whole story. She was henceforth very proud.

These clinical events marked by critical split-second decisions can only be handled by highly educated and trained physicians and nurses. It is our earned prerogative. It is the basis of our professional reputation and social standing. It is the largest feather on our cap. WE EARNED IT.

No bean counter that seems to enjoy harassing us with their micromanagement BS, will ever be able to match us. Let us continue to study and train intensively to continue being quasi-indispensable.

We love our Medical Profession and will practice it until the end of our lives.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.






Physician and Nurse Burn-out. Part XII – Losing Oneself

“The greatest hazard of all, losing oneself, can occur very quickly in the world, as if it were nothing at all.” Søren Kierkegaard

Søren Aabye Kierkegaard was born on May 5th, 1813, and passed away on November 11, 1855, in Denmark, and has been considered as the Father of Existentialism. In a great Wikipedia article they defined him as: “he wrote critical texts on organized religion, Christendom, Morality, Ethics, Psychology and the Philosophy of Religion, displaying a fondness for metaphor, irony and parables.” In his times there was a big emphasis on the Cartesian evaluation of Religion, highlighting its rational and communal aspects to better Mankind in general. But Kierkegaard was interested in a much smaller dimension, the one that traverses the daily lives of each and every one of us making choices that may lead to significant future changes of the same.

Last week we discussed in earnest how it was so critically important for Health Care practitioners of all genders to choose very wisely their life companion and partner. We have borne his protracted SARS-CoV-2 pandemic and the calamitous effects of so many months of Social Distancing, which we are only starting to see at the social, political, economic levels and public health seared an indelible scar on our minds. Imagine that each and every citizen of the planet has been methodically herded into an alley abutting to a cattle chute, where we have been all marked by Death itself. We pray for the Salvation of all those relatives and friends that succumbed but, above all, we pray for all of us who were left around for the next Walking Dead’s casting.

Note. This image form of Dublin’s Famine Memorial was taken from Wikimedia Commons.

The other day we came across in a Miami street with a colleague of ours from Columbia University that went into Intensive Care Medicine as a sub-specialty. He looked like he had put on, not 10 years since we last casually met, but rather some 40 years. He noticed our indiscreet staring and asked us: “So I look that bad to you, eh? And how about you? When was the last time you faced the mirror?” He was absolutely right as we, physicians, and nurses, do not dare to gaze into it lately.

However, we can make our sorry state of affairs even worse, much worse. How? For starters if the Health Care authorities continue to negate or minimize the existence of an extremely serious Mental Health epidemic in our ranks, especially for female colleagues. And if those deadbeat politicians in Washington D.C, continue their disgraceful pandering in search of votes by endorsing any wacky conspiracy theory.

As our Pope Francis said: “Either we come together out of this one or we do not.”

Brothers and sisters, let us not lose ourselves. We still got much more Life Ahead.

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Do not leave me alone.


Physician and Nurse Burn-out – Part XI. Our beloved Spouse

“On ne devient pas un fou si on ne le veut pas » Jacques Lacan

(We do not become crazy if we do not want to)

-“Mario is very special…Not any girl can become his girlfriend and companion.”

You know how girls love to meet and speak of us, innocent men, behind our backs. A few months before our graduating as physicians in La Plata, Argentina in 1981, a large group of girls convened a meeting in a restaurant to “rate us all for good.” Yes, naïve men out there , we are being scrutinized by these girls at all times.

Rarely did they ever allowed a boy in their meetings but my lifelong buddy Jorge, with whom we shared all the up and downs of the Medical School studies and is the godfather of our son Gian Luca, happened to stop by that resto and was let in. Most likely because he had the reputation of being the “super-nerd” of our class and he was deemed harmless enough to sit in the midst of all that feminine cacophony.

-“The first half , they rated each and every one of us,” he told me when he returned to our shared dorm. “And the other half ?” I dared ask. “About you and only you.” He was amazed that each one of our feminine colleagues took turns to, besides extolling my brilliant mind and savoir faire with the ladies (false modesty apart), they would opinionatedly select which one of them could be my fit Life Companion.

Note. This reproduction of a US Navy Recruitment poster was taken from Wikimedia Commons.

The Selection of Your Spouse is the single most important personal decision that a practicing physician must decisively make in his/her/ihr life. The very critical one. The aspiring candidates must all carefully be vetted with a hawk’s eye. No less.

So, fair damsel of catwalk looks, will you be expecting your hubby to arrive every day at 5 PM to share hors d’oeuvres and cocktails? No good. Get yourself a banker.

So, fabulous stud with those big muscles, will you be expecting your wife from the hospital to do the laundry, fix dinner and make love? No good. Go back to Mommy.

So, great fun of all parties, will you be expecting your exhausted wife to put a friendly face when you parade her in your yard gathering? No good. Join the clergy (any)

So, inflexible enforcer of Feminism, will you be expecting your man to drop  the CPR team busy in the ICU to listen to your harangue? No good. Join the Communists.

These are only a few examples of the hard scenarios that physicians and nurses must ponder before making that critical decision. AND ONLY YOU CAN MAKE IT.

You must be aware that when your spouse waves goodbye every morning to you, he/she/sie is in fact slowly lowering a high tensile steel cable of your harness to lay you in PURE HELL. She will then tie the cable to the strongest oak of the park. Loyally, she and the children will show up at a re-arranged hour to pull you back up. And do not commit the silly mistake of lingering around for a drink or chat, as you mind will be slowly eroded until you end up mad ( we saw several of these cases)  When your family rings the bell above, skedaddle out of that dark hole to preserve your sanity.

Down in the entrails of Sickness and Frailties, you and your colleagues will be fiercely battling all kind of demons and monsters, including some of your own making. Whomever gets distracted for a single second, runs the risk of being eaten. One of the most silly and dangerous mistakes of us, male physicians, is to get a Trophy Wife to brag to all our colleagues, patients, family. There is only a problem. As the knucklehead is more interested in finishing her bridge game with the girls at the country club, you arrive at an impossibly cold and chaotic house with no dinner.

What do most of us, stupid men, do? When the cute OR assistant gives us a wink in the middle of surgery, we arrange for a discreet date, to avoid our horrible hearth. So goes the cutie Med student, then the cutie in Admissions, then the cutie….Until one day you find yourself in the doghouse in the middle of a terribly cold night, madly trying to make Fido share his blanket. Fat chance. Fido knows you are a Sorry Loser.

Forty years ago I had to make that terribly decision and I think I made the right one. Now I am standing at that critical junction of my career path for a second time before deciding which one.

Will I be so lucky as to win the Lottery twice? Stay tuned. More to come soon. 

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.