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6/14/2017 1 COMPASSION FATIGUE: THE ROAD LEADING TO BURNOUT Richard Miller, MD FACS Professor of Surgery Chief, Division of Trauma, Surgical Critical Care and Emergency Surgery Vanderbilt University Medical Center Grand Rounds St. Charles Health System Bend, Oregon June 16th , 2017 Disclosure • None All patients or their families have given permission to show photos Vanderbilt: Spire Health and Wellness Collaborative HH- 1992 18 y/o Clemson student hydroplaned her VW on Interstate, crashed into schoolbus ISS 65 Transected aorta, bilateral hemoptx, multiple rib fxs Ruptured spleen, Grade IV liver laceration Complex pelvic, extremity fractures Arrived moribund with BP 50P SS 29 y/o/w/f 38 cal. GSW to abdomen • BP 80 / P through central portion of liver, stomach, pancreas, spleen expl. lap, L thoracotomy, cross clamp aorta for massive hemoperitoneum splenectomy, distal 2/3 pancreatectomy, partial hepatorrhaphy and packing, gastric repair • ISS 25 > 50 units blood / blood products

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6/14/2017

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COMPASSION FATIGUE: THE ROAD LEADING TO BURNOUT

Richard Miller, MD FACSProfessor of Surgery

Chief, Division of Trauma, Surgical Critical Care and Emergency Surgery

Vanderbilt University Medical CenterGrand Rounds

St. Charles Health SystemBend, Oregon

June 16th , 2017

Disclosure

• None• All patients or their families have given

permission to show photos• Vanderbilt: Spire Health and Wellness

Collaborative

HH- 1992• 18 y/o Clemson student hydroplaned her VW on

Interstate, crashed into schoolbus• ISS 65• Transected aorta, bilateral hemoptx, multiple rib

fxs• Ruptured spleen, Grade IV liver laceration• Complex pelvic, extremity fractures• Arrived moribund with BP 50P

SS

• 29 y/o/w/f 38 cal. GSW to abdomen• BP 80 / P• through central portion of liver, stomach, pancreas,

spleen• expl. lap, L thoracotomy, cross clamp aorta for

massive hemoperitoneum• splenectomy, distal 2/3 pancreatectomy, partial

hepatorrhaphy and packing, gastric repair• ISS 25• > 50 units blood / blood products

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Have you heard of Compassion Fatigue?

• Discussions regarding nurses and counselors• First diagnosed in nurses in 1950s• First described in literature in 1980s (Figley)• Also called Secondary Traumatic Stress

Disorder (STSD)

• Work with populations who experience traumatic events

• Work in a highly stressful environment• Jam packed schedule- yet need to be

compassionate EVERY DAY!!

Have you heard of Compassion Fatigue?

Compassion Fatigue

• Phenomenon that occurs when caregiver feels overwhelmed by repeated empathetic engagement with distressed patients/families

• Precursor of Burnout- manifests itself as– Physical– Emotional– Spiritual

EXHAUSTION

Compassion Fatigue

• Delivering too much bad news or prolonged periods of time dealing with difficult issues– Terminal illness– Critically ill/injured– Angry patient/family– Psychopathology– Permanent lifestyle changes

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TW

• 28 y/o female• Banking executive• First date• Passenger on MCC vs 18-Wheeler• Impaled by back bumper and thrown• Avulsion of perineum/abdominal wall

MG

• 47 y/o male• Train car hitch manager• Crush injury left pelvis/groin/leg• Hemipelvectomy/open abdomen• Multiple operations leading to STSG

to flank, abdomen, remaining pelvis

Cost of Caring•Charles Figley, co-author •Compassion Fatigue: Coping with STSD in those who treat traumatized patients and their families•“There is a cost to caring… Those who have enormous capacity for feeling and expressing empathy tend to be more at risk for compassion stress”

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KH• 4 y/o/w/f run over by minivan• BP 60 / 0• flail chest / severe bilateral PC• femur fx• hemoperitoneum • ISS 50• exploratory laparotomy - splenectomy, repair liver lac,

bilateral CT’s• 7˚later - tense abdomen unable to oxygenate / ventilate

oliguric• ICU decompression / Silo• MUSC

Incidence of Compassion Fatigue• Up to 85%!!• Feel they no longer had any compassion

left to give• Even after “restful” time off• CF take toll

– Decrease productivity– More sick days– Higher turnover

Warning Signs of CF• Diminished sense of

personal accomplishment• Exhaustion (physical and

emotional)• High self-expectations• Inability to maintain

balance of empathy and objectivity

• Less ability to feel joy

• Low self-esteem• Sleep disturbances• Workaholism• Anger/blaming• Abusing drugs, alcohol or

food• Depression

Burnout vs Compassion Fatigue• Compassion Fatigue:

– Continue give themselves FULLY but find it difficult to maintain healthy balance of empathy and objectivity

– Sucked into vortex that pulls you slowly downward– Can’t stop downward spiral– Work harder/continue to give to others until

completely tapped out• Burnout: adapt to exhaustion by becoming less

empathetic and more withdrawn/desensitized

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Burnout: What Is It?• A syndrome of psychological (and physical) exhaustion and

diminished efficiency resulting from overwork or prolonged exposure to stress*

* Encarta Dictionary: English (North America)

Depersonalization

Emotional exhaustion

Low personal accomplishment

BURNOUT

Burnout Eventually Becomes a Vicious Cycle

Futility, disappointment, and guilt

Interpersonal problemsand depression Health problems

Diminished performance

Lethargy, depleted motivationMALAISE OF THE SPIRIT

Symptoms of Burnout

• Health problems• Substance abuse• Chemical dependency• 6% exhibit suicidal

ideation• Most surgeons unable to

recognize they need help

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Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout - Carol Peckham/January 11, 2017

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VANDERBILT SURGERY

Work Unit Strategies

Gathering MD

Organizational Strategies to Protect Well-

Being

Recommendations and Approvals

Implementation

Communications

EvaluationStrategies to

Support High-Risk Individuals

VanderbiltTask Force for Empowerment & Well-being

Identification of Strategies

Compassion Fatigue/Burnout Therapy

• PREVENTION!!• 1st learn to recognize when you are wearing down• Come to terms with suppressed feelings of anger, fear,

self-doubt since early medical/nursing/EMS education• Take care of yourself

– Get into habit of doing something EVERYDAY that will replenish you

• Not easy: old habits comfortable even when bad for us• Real lifestyle changes take time, energy and desire

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Compassion Fatigue/Burnout Therapy

• Understand that emotional pain you feel is NORMAL!!!• Will dissipate once start caring for your physical and

emotional needs• Find someone to talk to: a GOOD LISTENER

– Connection– Spouse or friend listen without judgment – Colleague with first hand knowledge of CF– Senior mentor– Clergy– Support group

Develop your ownSELF-CARE PLAN

• Spend quiet time alone– Learn mindfulness meditation (being in the moment)– Reconnect with a spiritual source– Help achieve inner balance/miraculous turnaround

• Recharge your batteries daily– Commit to eating better/regular exercise regimen/adequate

sleep

• Hold one focused, connected and meaningful conversation each day– Time with family and close friends feeds the soul

Finding Community Support

• Building a culture of support at work is vital• Explore resources provided by your organization• Social support affects everything from length of

life to incidence of many diseases• It’s okay to start small• One example:

The Spire Story @ Vanderbilt

• Background: CF in the Trauma Unit• September 2013: Introducing the program … and staff cuts• December 2013: Excited employees, improved morale• Spring 2014: Expansion, throughout VUMC

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• Website and apps• Sharing

Accomplishments• Points and Peer-Support• Custom Rewards• Challenges and

Competitions

RESULTS!

Implementing Spire

• An important complement to external support

• Very well researched• Different levels• Example: Search Inside

Yourself – Chade-MengTan, Google software engineer and motivator

• Calm your mind, focus on being present

Mindfulness

Words of wisdom from someone who has suffered from Compassion Fatigue:

Find things that give your life joy and meaning

Take A Moment To

Appreciate The Beauty Around You

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Develop emotional awareness

Prioritize personal wellness

Find meaningin work

Connect with others

Personal Wellness

Physical Well-being• Fitness• Nutrition• Sleep• Healthcare

Mental Well-being• Hobbies/interests• Kinship• Alone/down time-

Mindfulness– Yoga– Meditation– Appreciate life’s blessings– Etc.

Burnout (ICD-10) =Z73.0, a state of vital exhaustion