How a code profoundly affected this physician [PODCAST]

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“There is a small amount of literature about secondary trauma. This means that the people who respond to trauma (firefighters, police, doctors, EMTs, etc.) experience PTSD from experiences they were not the primary victims of. I haven’t read the literature, and I don’t know what qualifies. I do know that this is the single worst experience with humanity that I have ever had, and the images from that night are as clear in my head today as they were when I first saw them. I know I will never forget that night, nor will I ever cease to feel my heart drop and stomach churn when I think about the few steps that Amanda took from her bed to the bathroom. The last few of her life.

Rehaan Shaffie is a hospitalist.

He shares his story and discusses his KevinMD article, “The worst code I ever ran.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Rehaan Shaffie. He is a hospitalist, and he wrote the KevinMD article “The worst code I ever ran.” Rehaan, welcome to the show.

Rehaan Shaffie: Thanks for having me. It’s very nice to meet you.

Kevin Pho: So again, we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Rehaan Shaffie: Yeah, absolutely. So I’m a hospitalist. I’m based out of Denver, Colorado, at a safety-net hospital here. I’m originally from Kansas and did my med school training there, and then I did my residency in the Bronx, New York, which is where the story takes place, also at a safety-net hospital. That’s been my chosen practice setting, and it has really formed my career and my experiences along the way.

Kevin Pho: So tell me what some of the challenges are practicing inpatient medicine at a safety-net hospital in particular.

Rehaan Shaffie: As you might imagine, the patient population is underinsured or uninsured in most of these locations. That influences not just the resources that we have available to take care of these patients, but all of the determinants of health that they experience. So it’s a high level of comorbidity, and it’s a low level of external hospital resources in terms of finding patients that have social support, who have not had experiences with things like incarceration, homelessness, and poverty. So it’s an intersection of social factors and medical factors that creates a pretty unique practice environment.

Kevin Pho: So as a hospitalist, what are some of the biggest differences that you could make for this patient population at safety-net hospitals?

Rehaan Shaffie: Yeah, I think that there are a few things we can do, and some of them are very personal, because the patients that we meet often view individuals who are a part of an institution the same way, whether that’s folks they interact with in the criminal justice system, in correctional care, or in health care. There is something that is official, bureaucratic, and administrative about all of these organizations, and whether or not we intend to be representatives, we are representatives of a larger system. By treating patients with empathy, dignity, and respect, I think that we can change the way that they interact with these systems, even on a small scale.

I think everyone has experienced this, where you have a patient who is, quote-unquote, difficult because of the experiences that they’ve had with representatives of a larger system. The more that we can do to treat them as human beings, the better those relationships will be, the more engaged they’ll be in their care, and, very optimistically, the better their interactions will be with representatives of different parts of that system more broadly. You know, we can deliver quality clinical care with a high level of compassion and hopefully create a reputation for our safety-net institutions that these are places that are representatives of the community and can influence public health in that way.

Kevin Pho: All right, let’s talk about the KevinMD article that you wrote. It’s titled “The worst code I ever ran.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Rehaan Shaffie: So the article takes place toward the end of my second year of internal medicine residency in the Bronx, at that safety-net hospital. It was a very high-acuity, high-volume, and low-resource environment, and along with that came a lot of exposure to critical illnesses. The article focuses on one particular experience I had during a night admitting shift. I was extremely busy, just taking care of multiple patients at a time, and a code was called overhead on the floor that I was on.

As I’m running that code, there was a patient who had recently come through the doors, who I had just kind of shaken hands with. We often do these visual assessments and rely on observation skills to determine if folks are sick. I just really briefly met her, and then she went to her room, and then she coded across the hall. So I had what I think is, hopefully, a unique experience of running two codes at the same time, running back and forth across that hallway. The article is about my experience doing that and the effect that it had on me.

Kevin Pho: So take us into that night. As you’re running the code, give us a picture of what you’re experiencing.

Rehaan Shaffie: As anyone who has been through residency knows, going to that code or that emergency situation at the end of your second year, I walked in with a lot of confidence. I walked in as someone who had run codes before, who had been a part of a lot of codes at that point, unfortunately, and I felt very good at the very start of this experience. And then everything flipped when the second code was called. There was a period of confusion where I thought there was a mistake, and I go across the hall and I see my medical student. One of those images that is always going to be with me is looking at his face. He’s so pale, and he’s standing over this woman that we had just briefly met, for less than a minute probably, and everything changed for me.

I was very calm, you know. I felt like I had my heart rate under control and my breathing under control, and I felt like I was anticipating this ACLS algorithm to walk through for the first patient. Then when this happened, I sort of had that feeling that I had at those very first codes, where your heart rate goes up, your face feels flushed, you start to sweat, and all of a sudden there’s this pressure on. Thankfully, the med student was excellent, and he was there, and I was able to ask him to start compressions, and he did. I think as soon as we started that first step, my sense of the algorithm kicked back in.

And then I don’t think I was very internal at all for the next 15 minutes. It was very external, so I was really focused on the algorithm and just keeping track of where I was going between rooms and focusing on what needed to be done. It wasn’t until several days later that I really had a chance to sit down and process what had happened, which I think is really typical of a lot of the critical situations and a lot of the traumatic situations that providers find themselves in. There’s not time in the moment, and there’s not space in the moment, to process those.

Kevin Pho: So as you reflected on that experience, what kind of conclusions?

Rehaan Shaffie: Well, I think from a personal and professional perspective, it did end up actually giving me a little bit of confidence that I could do things and push myself in ways that I would, very objectively, find uncomfortable, and as a result, that made me more comfortable in future situations.

I think in terms of coming to the point of writing the article and reflecting on it in that way particularly, it became obvious in the last two years of the pandemic that there should be opportunities to reflect on experiences that are really life-changing. Sometimes, I think just because of the nature of what we do, we don’t fully appreciate how life-changing it is to see someone die, or to touch them in their last moments, and to be trying to bring them back, and to be unsuccessful or successful. It’s still just a really monumental life experience, and there aren’t many avenues to share those.

I think the most impactful part about that experience was really at the very end, which is that I just went back to work. Maybe even more so than the fact that there were two codes going on at the same time, it was the idea that in this job, you just go back to work. There are a few other jobs like that, for sure, but it really just made clear that we have to find space to process these things and to deal with them the way that they should be dealt with, and I don’t know if we really have an avenue like that right now.

Kevin Pho: So in your residency program, after you had that horrific call night running two codes at once that affected you to the core, how about your peers and chief residents? Did you have any formal debriefing period, or was that just considered a typical night?

Rehaan Shaffie: It was more along the lines of a typical night, really. You know, residency is one of those unique and really special experiences where you do become so close to the people that you’re with, because no one else will ever have the experiences that you have. So you do have that support system, and I did really rely on my co-residents, you know, seniors and juniors, and that medical student who shared in that experience with me. But there wasn’t that formal debrief. You know, as the senior resident in charge of the code team, you just keep going, come back the next night, do some more admissions, do some more codes, and try and do it better.

Kevin Pho: Now, from a teaching standpoint, I’m sure that you’ve got a lot of lessons to give that particular medical student, but just for other new residents in general who are going to be confronted with something like this, what kind of advice can you give them to better prepare them for this experience?

Rehaan Shaffie: I think the advice I would give them is advice I give a lot on teaching rounds as well, which is that the best learning is when you feel uncomfortable. Whether that is something small on rounds, such as taking the opportunity on rounds to tell your attending that you don’t know something and feeling the discomfort of that, it will drive home the lessons that are coming much more concretely than any other experience, than any other response.

I think the same applies in a code situation. At the beginning, you’re learning, and you have to be willing to walk into a room and declare yourself the code leader and use the knowledge that you have to start that process, and then use your team members, and tell them, “Hey, there are experienced nurses who are going to be around you, experienced RTs who are going to be around you, other folks on the code team.” And you say, “Hey, what’s next? What am I missing? What am I not thinking of?”

I’ll still ask questions in a code, which I think ultimately, at the beginning, is a sign of being a learner, and I think as you become more experienced, it’s a sign of being a good leader, because that room is full of people with knowledge and experiences and perspectives. If you don’t utilize all those, you’re just taking tools out of your toolbox.

Kevin Pho: Yeah, I think that’s a wonderful point, because sometimes when you’re running a code, you have that compulsion to pretty much do everything, and you lose sight of the fact that you do have experienced respiratory therapists, nurses, medical students, and your co-interns and co-residents helping you out. In that moment, sometimes it’s hard to draw upon their help.

Rehaan Shaffie: Yeah, absolutely, especially as a resident, because you do feel that pressure, you know, whether in your mind or whatever it is. You just feel like the spotlight’s on you, and so it’s hard to take a step back and think about all the other people in the room and what they have to offer.

Kevin Pho: So experiences like these, how did they prepare you for, say, the pandemic over the last two and a half years? Because I could imagine you’ve had equally intense experiences during the pandemic as a hospitalist.

Rehaan Shaffie: Yeah, I was speaking about this with a colleague the other day, actually, and we decided on the term “learned resilience” as something that we really appreciated from our training. There are multiple ways to be resilient, and there are multiple ways to become resilient. I think that with the experiences that I had in residency, and that one in particular, there are two responses coming out of that. One is to really let it affect you in a negative way, and the other is to try and find ways to process it in a healthy manner and become more resilient as a result of it.

I certainly didn’t do that alone. Like I said, I had co-residents. You know, I have a family and a support system. I’ve gone to therapy; a lot of people have gone to therapy. There are multiple ways to recognize what it does to us and to deal with it in a healthy way. I hope that more people who have these experiences realize that it can eventually become something that builds that feeling within you, that resilience within you.

Kevin Pho: So you mentioned that you went to therapy to help debrief you and help you process these traumatic experiences. Now, not every physician does that, right? Seeking behavioral health help sometimes is interpreted as a sign of weakness, and physicians are supposed to tough through situations like this. What was your decision-making process in terms of seeking behavioral health help?

Rehaan Shaffie: Yeah, I think I was very lucky to have friends and family members who had more mature perspectives than I did at that time. Especially as a trainee, I was very much a part of that culture, that mentality. You know, you tough it out, you go to work when you’re sick, you deal with these experiences, you make jokes about them, you’re just tougher and stronger and you have a thicker shell, and you just keep going. I had people within my social circle who helped me reflect on what those experiences were like from an external perspective. Like I said, if you’re able to take a step back and realize how remarkable and rare it is to have your hands on someone when they die, it is a really remarkable thing. So having other people be able to provide that perspective to me helped me reach a point where I realized it was something that I needed.

I think that coincided with this realization that it also wasn’t going away because I just went back to work. Because so many of us just do go back to work, it’ll never go away. I thought about that experience, honestly, probably once a week until I wrote the article, because you just keep moving, and no one will ever come back and ask you about the things that really impacted you and really made you uncomfortable and were really traumatic. After all these years, still no one had asked me, and no one was ever going to, and so I just needed to tell the story. Those things kind of came together and made me realize, “All right, you’re going to have to find a way to tell the story in healthy ways for yourself if you’re going to keep going in this profession.”

Kevin Pho: So when you talk about these external perspectives that people not inside of medicine gave you, you mentioned some of them told you how rare it is to have your hands on someone as they die. What else did they tell you? I’m interested in hearing what other external perspectives kind of swayed you.

Rehaan Shaffie: I think also hearing that it was very common to go to therapy, it was very common to share traumatic experiences in other settings, and it was very common to process those things without a culture that promotes pushing that down and moving on and getting on with the work. That was helpful for me, to understand that medicine can feel so insular at times in the way that we do things, and it’s hard to see how other people do things in other industries or other professions. And then I think when you start to realize that, it’s a helpful perspective, because it showed me, “Hey, there are other ways to do these things. It doesn’t have to be this way.”

Kevin Pho: And my final question: What are some of your take-home messages that you want my listeners to come away with after hearing your story?

Rehaan Shaffie: Hopefully people feel very motivated to talk about the really important experiences in their life, and specifically within their career in medicine. Hopefully they seek out ways to do so without being asked, and they seek out resources that make them feel empowered to tell those stories, whether that’s writing a blog post or speaking with their partner or that family member (this was not a story I had even told my wife), or going to therapy.

I think there are so many things that we do that are really unique to our experience as physicians and as human beings, and the last two years for everyone in medicine have been full of those experiences. So I know that everybody has them and everybody has that story. I also know that we’re moving on, and we’re all moving on to the next thing, and we’re getting ready for the next phase in our career. But we just lived through a once-in-a-lifetime event, and we experienced a lot of things that many people will never experience again, and I think that it’s worth talking about.

Kevin Pho: Well, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Rehaan Shaffie: Thank you. I appreciate the opportunity.

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