Medical Burnout: It’s the Little Things

Medical Burnout: It’s the Little Things

By Lynette Roggenbuck

In the emergency room (ER), they would assign me to our trauma bay. Here, we would triage and treat any patients coming in by ambulance. I would help the nurses assigned there to answer the EMS radio, obtain vital signs, and collect any needed blood work for the lab to process, etc. Since I worked the midday shift, the ER was always busy. It wasn't uncommon to have six or seven triage patients backed up in the hallway, as we work with a trauma bay that only fits two patient beds. Often, if the trauma bay got busy with a critical patient, like a CPR in progress, or could not move their patient out of the bay into a room in the ER, I would begin going down the line of waiting patients. I would collect their vital signs and assess their complaints to prevent them from waiting until the triage nurse could admit to the ER. Triaging patients and coping with the lack of needed space was hard enough, but the ER also had patients coming in through the front entrance, waiting to be placed into a room and seen by the doctor. Desperate to move patients along, less critical patients who did not require monitoring with an EKG or other devices would be placed in the hall for the doctor to see, the same hall where my ambulance patients would back up as they waited triage and placement as well. To say the ER floor was often chaotic would be an understatement.

Swamped with patients, I obtained vital signs on a patient brought in from dialysis for abdominal pain. While I was taking his blood pressure, the EMT assigned to the front desk placed a patient in the bed in the hall behind me. I never learned her reason for coming to the ER, but critical patients weren’t assigned to hallway spots, so it was relatively minor.

I think she asked me for something like ice water, but while triaging a patient, I told her she would have to wait until I finished or the tech assigned to her section came to check on her.

This was unacceptable. The patient ridiculed and insulted me to her companion for the next twenty minutes. Unfortunately, since I had to finish triaging my patient and there were no available rooms to send him to, I gritted my teeth and did my best to ignore her. While I started an IV line on the patient and collected blood samples, I endured being called "lazy," "stupid,"

Burnout/Roggenbuck/1 and every colorful vulgarity possible delivered with the righteous passion of a middle-aged soccer mom trying to use expired coupons.

"No one in healthcare cares for patients," she told her friend. "They just care about money." I tried not to react as I taped up the new IV line. Barely scraping by between paychecks while fending off student loans, insurance, and rent, whoever was in healthcare for only money, it certainly was not me.

I grabbed the glucometer to measure my patient's sugar levels in his bloodstream, remembering the paramedics had told me he had diabetes. It would need to be monitored during his stay, so we needed a baseline reading.

Typically, healthy blood sugar is 80mg/dl, and below 70 mg/dl is considered dangerous.

A 55 mg/dl reading or below can lead to coma, seizures, and death.

My patient's reading was 22mg/dl.

It was my turn for vulgarities, but only mentally. I alerted the nurse to the situation so she could grab the dextrose from the medication dispenser. We had to correct the patient's sugar ASAP. Triaging my patient had gone from routine to critical in less than a minute. I ran toward the doctor's desk to get a physician to examine him immediately, coincidentally past the rude patient in the hallway.

"Why don't you learn how to do your fricking job?" she called as I hurried past.

I went outside to cry afterward. The stress from helping the mildly sick to the critically injured had been manageable. I had managed to juggle triaging new patients, placing them in rooms to make room for the flood of incoming patients, and passing reports to the new nurse. I barely noticed the ache in my feet from hurrying back and forth during the preceding four hours of my shift, where I had been so busy I had forgotten I had to pee at least three times. Working in the ER was stressful, but I had always expected it to be. The variety in routine and intense, sometimes graphic nature of the work was something I had expected, something everyone in emergency medicine expects. It was stressful, but never too much.

The verbal abuse had made it too much.

Many factors go into what causes medical staff to burn out, from poor work-life balance to understaffing. All of it piles up until one day while lying in bed before their shift, to realize the

Burnout/Roggenbuck/2 very thing nurses and doctors spent years working toward is now the crushing weight filling them with dread.

One factor causing burnout that is never a part of discussion is the sheer amount of verbal abuse medical staff face daily.

Being abused by employers and patients ground away at me until it felt like I had nothing left. My emotional tank was empty, but still more was demanded of me. Pushing past this point burnt all my reserves until I felt charred and numb inside. But there are always more calls coming in, more patients walking through the door, and never enough staff to help stem the flood work.

The bosses always assured us they would hire more staff. They promised to look into budgeting once they returned from their vacation in the Caribbean. Then we would find out they turned down a four-cent raise for staff but somehow found the money to give each board member a one-thousand-dollar bonus. After months of this cycle, I’d collapse into bed after a twelve-hour shift, exhausted and knowing I’d have to go back tomorrow for another. While lying there, it dawned on me that I couldn’t remember the last time I felt joy at reading a book, doing a hobby, or being around people didn't feel like an exhausting chore.

By this time, I had worked as a paramedic in the ER for six months and in the ambulance in the metro-Detroit area for the previous two years. Most of the medical staff I worked with showed signs of burnout. It happens to everyone eventually, especially when performing a high-stress job like the ER. Every doctor, nurse, and EMT has many stories of being insulted, berated, and even assaulted during their shifts. I watched a disgruntled patient try to punch a charge nurse repeatedly. Sexual harassment from patients occurred so often that no one bothered to report it to management. Even when we did, the patients were still entitled to medical care. We couldn't tell them to leave. We could ask that we not be assigned to assist with the patient anymore, but staffing shortages made it difficult to shift the patient load around. More often, it felt like we were expected to absorb the abuse hurled at us unflinchingly.

After hearing I worked in emergency medicine, people will ask for "the worst call" I ever had. They want to hear about the gory traumas with blood-covered car-accident victims or the workplace accident where a worker shaved all the skin off their hand, leaving it flapping like a

Burnout/Roggenbuck/3 fleshy glove off their wrist while the bloody jagged tissue of their hand was exposed to the open air.

Otherwise, it's the emotional calls they want me to recall: the ones that pull on medical workers’ heartstrings. They imagine the blare of the lights and sirens deafening their ears. I once attended to an unresponsive infant. I pumped my thumbs against the chest of a barely-month-old baby. My joints ached, but I barely noticed as I counted out the familiar rhyme to try to start the little heart pumping again. People think of situations like these when they hear "medical burnout." They think of a version romanticized in film and books: the call that will instantly break the spirit of even the most persevering medical provider. However, in my experience, this isn't the case.

Burnout is gradual. It's a long, drawn-out process where stress piles up on healthcare workers without relief. It's not a lightning strike followed by the sharp crack of a branch.

Burnout is the emotional 'death by a thousand cuts.' It’s the raw ache in your chest that feels like the sooty ash leftover from the coals of a dying fire.

Each time a patient screams in a nurse’s face about the long wait times adds another link in the chain, weighing them down. The administration tells employees they can't afford to give anyone a raise despite being understaffed with record patient numbers. A patient calls the technician "lazy," "stupid," and many more colorful adjectives because a ten-minute wait turned into an hour wait. She doesn't know an ambulance brought in a thirty-year-old dad who collapsed on the soccer field, and her doctor spent over an hour trying unsuccessfully to make the man’s heartbeat again while his wife watches and sobs nearby. The buzzing fills my head, so after twelve hours of constant hustle and noise, it's still loud even as I drive my car home in silence.

Besides the patient abuse, we had to deal with abuse from the administration and corporation. This abuse always felt more subtle. They may not have spit in my face or shrieked expletives so loud my eardrums hurt for hours, but they always seemed to make us feel disposable, just faceless cogs in their business scheme, profiting from illness and injury.

When the business department examined how each department could cut expenses, the ER director told us once, during our beginning-of-day meeting, that they were thinking of cutting the paramedics on the ER staff and just going down to only having EMT-basics to assist the

Burnout/Roggenbuck/4 nurses. Our director told us she had fought and won the ability to keep us on staff. All the nurses we worked with angrily criticized even considering getting rid of us. We were invaluable to them.

Each time I arrived at my assigned section, the nurse would profess relief that I was assigned to help them. The techs were great, but I had a higher medical license as a paramedic. I could do a few more tasks than techs were allowed. The nurses knew they could get more done since I would be able to take potential spinal injuries to CAT scans or start an intravenous line for medication rather than only being allowed to draw blood.

What was the reason the business department cited for wanting to lay off all the paramedics? They had to pay us more. Employing only techs would be cheaper.

The business administrators had never worked in the ER. They never had to deal with the overwhelming number of patients coming in for treatment. They never saw how hard the paramedics worked or how valuable the nurses thought we were. They never cared about how helpful we could be by freeing up rooms by helping discharge patients or running a patient down to a CT scan to maintain spinal precautions because the nurse was too busy, and the techs weren't allowed to take them. I was just a number, an expense they didn't want to pay on a spreadsheet. While the ER director and nurses were successful in keeping us employed, the knowledge of just how quickly the bosses were willing to cut us out was not something I forgot.

It told us all exactly where the hospital's ultimate priority was.

For ER nurses, there were always more patients to see and more work to do. Their mental and emotional health often was thrown by the wayside in the name of reducing waiting times or improving satisfaction ratings. Other departments mandated nurse-to-patient ratios.

The administration implemented these mandates to reduce the chance of nurses making mistakes from overwork. Intensive care allowed only two patients for every nurse since they received the most critical patients. Step Down, where patients went after improving in intensive care, had a four-patients per nurse ratio.

In ER, nurses would be assigned up to six or even eight patients, sometimes with one or two critical patients mixed in. The charge nurse would try to contact any on-call nurses to see if they could come in if we were overwhelmed, but if not, there wasn't much else they could do.

Critical patients were placed since they needed immediate care, but the non-critical patients also needed to be seen eventually.

Burnout/Roggenbuck/5 This we understood, but the "tough shit" attitude that came with it was dismissive and dehumanizing. I'd help the nurses as much as possible, but my license to practice only went so far. Some things had to be done by a doctor or nurse. I'd seen more than one nurse asking the others for help because they were overwhelmed by a critical patient on a ventilator that had to be constantly monitored and couldn't attend to the other patients they were assigned. The nurses I worked with were troopers and always did their best to support each other, but sometimes they were just as overwhelmed. Intensive Care was worried that two patients would be too much and cause the nurse to make a mistake detrimental to a patient's health. How likely were mistakes in the ER, where nurses were juggling six or eight patients? But, to the administration, our wait time numbers looked good.

The administration told us often that we were in customer service, like working in a restaurant. The patients were our customers. Their money is what funded and ran the hospital.

A bad review online may cause patients to go elsewhere. Thus, we needed to treat them with the same amount of hospitality. I sat through their huddles listening to this and thought I'd never heard such a load of bull. As much as the administration wanted to think otherwise, a hospital is not a restaurant. People can't go into a hospital and order two five-milliliter bottles of morphine to go. Please. A restaurant customer received the order they wanted. A patient received the medical care they needed.

One of the nurses I worked with was relatively young and from Japan. She was the sweetest person I'd ever met and never spoke harshly to anyone. One day, the patient she was assigned to started cussing her out and calling her racial slurs. She tried her best to be professional, but she snapped after a half hour to an hour of his abusive tirade. She told the patient to "shut up." Unfortunately for her, that was the exact moment the charge nurse walked by. Rather than ask the nurse what happened, she reprimanded her. She called her unprofessional. The young nurse went to break down in the bathroom while the charge nurse apologized to the patient who had verbally abused her. The charge nurse was worried the patient would file a complaint.

Two or three months after I had started in the ER, the hospital I worked at was bought out by a new corporation. The company sent analysts to review each department as part of the transition. They wanted to determine if departments were running efficiently or were being staffed correctly. We were all nervous since this possibly meant layoffs. No one wanted to be unemployed when we all had bills to pay.

Burnout/Roggenbuck/6 While the hospital was usually busy, we did fluctuate in patient load. It was what many doctors, nurses, and paramedics in emergency medicine appreciate about the job: no two days are the same. We also had a busy period, flu season, and our slow season around July/August.

During flu season, we needed all hands on deck. Even fully staffed, we were hard-pressed to adequately treat the patients coming in. Wait times would shoot up to almost two to three hours for patients just to be seen initially by a doctor for non-critical cases. That didn't include the wait time needed for a test run and analysis.

So, when did the new corporation decide to assess our staffing needs? When we were flooded with patients and needed more staff? No, of course not. The critical time they chose to examine was when we were in our slowest month. It could have been a coincidence, but flu season is notorious throughout the medical field. No one in the ER was happy about the announced time. The prospects seemed to be either unemployment or being kept on, but then highly overworked when flu season hit. We only had half the medical providers on staff to handle the crowds of patients arriving in a few months. In the end, our ER director, an RN herself, was able to avoid anyone being laid off by reducing everyone's hours. While the situation seemed resolved from the outside, the emotional damage to morale remained.

The idea that a medical corporation wouldn't know when its client load was smallest and when it was most busy seemed highly unlikely. The consensus among staff was that they chose the slowest months on purpose. The administration wanted to cut as many staff as possible to reduce labor costs. Rumors flew everywhere. Allegedly, the Cath lab was assessed for necessary staff during the months they were temporarily shut down. Whether true or not, the analysis and the rumors added to the feeling of being misunderstood and taken for granted. It was not a helpful feeling pressing in everyone’s mind while we fought to resuscitate a patient or cleaned an incontinent patient with odorous diarrhea from C. diff bacteria. The job is hard enough. None of the medical providers expected trophies or to be placed on a pedestal, but neither did we want to be treated with such callous disregard.

Unfortunately, the blatant disregard for medical workers' humanity isn't limited to hospitals. It would be some years before I learned about "lean staffing," the deliberate understaffing of a workplace to attempt to cut costs. This practice puts the burden of covering callouts on staff to allow the business to function. I, unfortunately, found it commonplace in private ambulance companies. I did my clinical training for paramedic school in a rural area.

With the lower population and farther distances between the country homes and the city, there

Burnout/Roggenbuck/7 was only one ambulance company in the area. The remote areas only had volunteer fire departments and ambulances since the counties couldn't afford to fund a public service. Still, the private companies considered it unsustainable to move a response base farther out.

The paramedics that mentored me constantly complained about being short-staffed.

Their regular shift would last for a twenty-four-hour period. Sometimes emergency calls would come in late during their shift, and they would have to stay longer. If a coworker called out sick, one of the paramedics often needed to stay for an extra shift, so the area still had an ambulance in service. It was common for paramedics to stay for forty-eight to seventy-two hours in a row. In theory, they should have been able to sleep at the station between calls. However, emergencies don't follow a schedule. They don't wait for workers to rest. Sometimes a shift wouldn't have a single call the whole day and night. Occasionally, we're lucky to sit down for five minutes before the tones on the radio drop again.

When I worked in the metro-Detroit area, my regular shift partner asked me to pick up a shift with her for overtime since she hadn't wanted to work with the other medic scheduled. It gave us a thirty-six-hour shift. Our supervisor tried to be as considerate as possible with us. He ensured we were stationed at one of the bases so we could have actual beds to sleep on and informed the dispatchers not to give us any transport calls, only 911's. He promised to check in on us when he returned in our last twelve hours and send us home early. It would be nice to get out of the truck and possibly catch a nap between calls instead of staying squished in the ambulance cab.

The first tone dropped at 10 am, four hours into our shift. We didn't return to the station until 2 am the next morning. The calls came back-to-back: chest pain, flu-like symptoms, back pain, and difficulty breathing. When we finally returned to the station, I crashed the moment I lay down. Beep-beep-beep-beep. The emergency pager woke us up, but I felt great. I figured we had gotten at least three or four hours of sleep. I looked at the clock: We had slept for one hour.

The good news, at least, was that no one else was around to hear the colorful vulgarities I used.

The most unpopular policy at the private ambulance company I worked at was the "one-hour holdover." As well as responding to 911 calls, ambulances transport patients needing observation or assistance between hospitals, doctor's appointments, dialysis appointments, etc.

When the company took on too many for the number of ambulances in service, or when too many transports experienced unexpected delays, then to catch up on arrival times, the company would send out a mandatory notice: Every crew that had not yet been cleared to head home

Burnout/Roggenbuck/8 would have their end of shift time delayed one hour. This usually resulted in each crew having to do at least one more transport before they could head back to base and go home.

While they may have seemed reasonable on paper, one hour's hold shortly became the bane of my existence. A work-life balance was impossible. My regular shift was already eight to twelve hours. Planning any after-work activities or appointments was often fruitless, as every time I made plans, the inevitable holdover page seemed to steamroll over them.

As emergency responders, we were willing to accept occasional shifts that would run late. Emergencies didn't wait for convenient moments. Responding to last-minute chest pain or difficulty breathing meant meeting friends would get pushed back, or someone else would have to pick up the kids after work. The paramedics I knew accepted this as just part of the job. No one wanted to leave a patient in need without care, even if it meant sacrificing our time.

With non-emergent transports, however, it was much harder to swallow. The company was never willing to accept fewer transport calls. A smaller call load may have meant fewer holdovers, but it also meant less revenue. Instead, the company preferred to discount company morale and work-life balance.

This created a terrible turnover cycle. Scheduled transports ran behind so often that holdovers were issued with increasing frequency. Burned out, EMTs and paramedics resigned.

Not wanting to take fewer calls despite having fewer staff, the company pushed more holdovers.

More employees would quit. On and on the cycle went. Hiring new staff kept the company going, but the average duration an EMT or paramedic worked at the company dropped. Our more experienced paramedics moved on.

When I had been at the company for a year, I was one of the more senior paramedics. In an emergency response position, it was a scary thought. It was a job in which learning from a textbook only goes so far. The paramedics with years of experience handled unexpected twists and situations that needed a calm head better than new paramedics. Instead of retaining them, the frustration and burnout from the holdover calls pushed them to companies with no holdover policy or to the hospital with set shift hours. I, too, eventually switched to working in the emergency room.

While working in the ambulance, my work-life balance was nonexistent. When I first received my paramedic's license, one of the older paramedics pulled me aside to congratulate me and give me a pep talk. He said that my opportunities to make money had just opened

Burnout/Roggenbuck/9 because there was so much available overtime for paramedics due to staffing shortages. To me, this didn't sound like the opportunity he boasted of. Sure, I would be able to make time and a half on overtime, but that also meant I would be spending more time at work and unable to relax or unwind or see my family and friends. No time away to decompress from a stressful day or difficult call.

The company acted, at best, dismissive of people's obligations. Once again, we were simply cogs in a machine, numbers on a page, and an apparatus to run the company and turn over a profit.

About a year after I started working on the ambulance, I put in for time off for a weekend trip to Chicago. The way shifts worked was that I was scheduled to work every other weekend.

The weekend I wanted to go to Chicago for a writer's retreat fell on my work weekend. This wasn't too big a deal because I just had to put in for time off for my shift. Since weekends were usually short-staffed, we would offer to work a different weekend in return. This way, we could get the time off and still have coverage for at least one weekend.

My supervisor said that I could work the weekend before, which would be no problem. I just had to remind him when my time off got closer. When I was a month to a few weeks out from my trip, I called my supervisor to remind him of our agreement. Every time I called, he was mysteriously out. He didn't answer my calls. He avoided talking to me. I figured he had already approved my schedule, so I booked and paid for my trip.

The schedule came out, and my weekends were not changed. It was obvious that my supervisor had no intention of honoring his agreement. However, I still tried to call him. Perhaps he had just forgotten.

Finally, two days before my trip, the supervisor finally answered. I reminded him of my trip. He said he would have to deny my shift switch. He apologized but told me they did not have enough coverage and that I should have called him sooner if I wanted the time off. He said that now I would have to call out, but if I did, I would receive attendance points for missing my shift.

I told him I would take the points and call out.

To this day, I don't understand how he thought that would work. I had already paid for everything. I didn't call out often. I was a good worker and had earned my time off. Regardless of their job, everyone needs time off to decompress and enjoy time with family. Medical workers

Burnout/Roggenbuck/10 do not forfeit this because they work in health care. If anything, the job's stressful and often traumatic nature makes time away more critical.

Working as a first responder or medical provider often takes a toll on the body.

Sometimes, it looks like they've chain-smoked for twenty years. The physical work of lifting and caring for people is punishing. The stress of the work and often verbal abuse from patients eat away at their mental health.

The healthcare industry is in crisis. Nurses, paramedics, and doctors face national shortages of colleagues to share the work. After Covid, the burnout rate among healthcare professionals is higher than ever. Understaffed, underpaid, and unappreciated, our healthcare providers leave the industry when we need them more than ever. This trend must be reversed, but to do that, we must understand what causes it.

I have found that the little things more often build up to kill the inner passion driving healthcare providers. The dehumanization of workers is a factor of burnout that no one discusses. Whether it's being treated like a number on a spreadsheet by the healthcare corporation or whether it's being treated like a number on a spreadsheet by the healthcare corporation or like an emotional scratching post to be verbally abused by patients, the effects on doctors, nurses, and paramedics' mental health are the same.

We must remember that while they are present during people's most vulnerable and difficult moments, they are just as human and fragile as those they care for. Until we are willing to treat them as people, burnout will cost us many more excellent medical providers every year.

It is time we stop treating medical providers as cogs in a machine. Instead, it's time to start treating them as fellow human beings.