Epidemic Leadership. Larry McEvoy
as a clinician.
Despite the team's skill and my experience, a creeping dread wells within me as I scan up and down the hallway. It is my birthday, and while I am used to working holidays of all kinds and at all hours, this particular moment collides jarringly with all my years of effort, learning, triumphs, mistakes, hopes, and deaths in an unsettling pang in my gut and chest. In every room in our emergency department that night, while the ill and injured are getting what they need and we are chewing steadily at the backlog of patients piling into the waiting room, a bigger problem waits—no, grows—outside and beyond, unhurried, unstoppable, and inevitable. Nowhere does this unsettling gloom stick more than in my nose. The smell of blood, alcohol, feces, urine, antiseptic wipes, plastic tubing, vomit, and air freshener mix in my nasal cavity and settle like fine dust into my brain. Years before, when I was thinking of medicine and not yet doing it, I might have gagged. Now I just take a deep breath. It is not the smell of living.
“What you thinking, Scary Larry?” Dana, the charge nurse, appears at my elbow with a slight tug. “Big things or right-now things?”
She and I have worked together long enough to have earned our mutual nicknames for each other: Super Nurse and Scary Larry. I have worked with her while she handled two critically ill patients as the primary nurse while she held the charge nurse helm at the same time in the middle of the night. She can meet the wave. She knows my tendency to arc from micro-focus on the things at hand to macro meanderings on the source and end of what we see. She's more practical and fixes her mental gaze on getting through the shift.
“Big things,” I say.
She smiles, and the tug turns into a nudge. “Keep moving. We can hear about it later when it quiets down.” She gives me a wink before she moves past me: Shifts don't run us, Scary Larry. You and me—we run them.
As I suspected it would, the night swells into repeated waves of patients. They are unique and different individuals, but the patterns are familiar: strokes, heart attacks, overdoses, self-mutilation, asthma, domestic violence, rodeo mishaps, farm trauma, bar fights. I keep moving, patient to patient, through late Friday into early Saturday morning. Until then, I don't eat, and I don't go to the bathroom. Neither does anyone else on the team.
The shift eventually ebbs like all waves do, falling back quietly into the night. By 4:30 in the morning, only two patients are left in the department. Both are resting, with no surprises lurking. One of them snores under a morphine blanket covering the pain of a broken leg, and the slow sound keeps the tempo of the deep night.
Five nurses and I sit at a round table a few feet behind the high counter of the nurses' station. I'm sifting through some blood and urine culture results from the lab, and they are getting ready to “count narcs,” the frequent process of ensuring that all the potentially addictive drugs we use are all accounted for. I am reminded of being in a duck blind as a young boy with my dad, waiting out of the wind for ducks to sail in and disturb the quiet water around us.
“Good work, everyone. We cleaned up that board nicely,” Dana says. She pulls out her auburn ponytail and redoes it. “And now, Scary Larry, what were those big thoughts bouncing around in your head while we were all moving so fast last night?”
“I was just thinking we're getting killed. What's outside that door is growing faster than we can keep up.” I saw them looking at me. One of them rolled her eyes. “And it's getting bigger, not better.”
“What are you talking about?” Mavis had been in the department a long time. She grew up on a wheat farm in eastern Montana and had worked hard her whole life. “Five years ago it would have taken us a whole day to get through what we just did in eight hours. We were rolling.”
I smiled even as my bones felt heavy with fatigue. “It's not that. We run a shift just fine. Better and better every day, really. But society creates more disease, manufactures it actually, faster than we can keep up. The harder and better we work, the farther behind we are against a disease burden that's getting bigger, not smaller. Not in the shift, not in the department, but in the big picture. You ever have that feeling?”
“All the time … and then I stop thinking about it,” said Kim. “It's too much for me. Too big. I just think about my kids and my family and try to be a good nurse.”
“What did you expect? It's an emergency department,” Judy said. “People get sick and injured in more ways than anyone could imagine, and we pick up the pieces.” Judy had worked in the department for 15 years. In her view, humans were fallen and flawed creatures, and we suffered the consequences.
“I think of it as job security,” said Shelly. A couple years later, she would be a nurse practitioner and would leave us for the cardiology department. “No illness, no disaster, no job.”
The Problem That Won't Go Away
They were right and sane and rational, of course, those exquisitely capable nurses in the middle of the night at the tail end of a busy shift. Living and working at the back end of a massive bloom of unhealth and disease tends to make us feel very small. Think about it too much, and you go nuts. You can only go without food and bathroom breaks for so long. You have a job and a family and a life. The shift ends and you have to get some sleep.
Yet the question remains: What will we do about these “too big things”?
As good as we were that shift in August 2003, we were falling behind then, and we are falling behind now. The prevalence of illness we were dealing with that night was—and still is—ominous and exponential: we have epidemics of obesity, high blood pressure, domestic violence, opioids, anxiety, cervical cancer, smoking, meth, HIV, teenage suicide, disinformation.
We have created fancy, distancing words for these things—disease burden, pathology, psychosocial determinants of health—but up close, staring at you with sweaty foreheads and bluish lips, gushing out of wounds, groaning from half-opened mouths, these words cannot sterilize the sensory experience: sickness is on the move.
We spend hundreds of millions of dollars creating a vaccine for influenza every year, educating people, holding flu shot clinics, and influenza still erupts every single year. Worse, when you look at what causes illness and death, lost wages and jobs, lost productivity and the high societal cost of health care, you find a sobering truth: we are creating the epidemics we are trying to stop. They are not mere accidents.
As a doctor intent on creating the reversal of injury, the return to health, some sort of positive impact for and with the patients I cared for, the scale of it drowned me that night in 2003. I had been trained to treat disease and injury, to pull alongside ailing people and, with my hard-earned priestly wisdom and science and human compassion, help them restore themselves. Sometimes it worked, sometimes it didn't, but I had not anticipated that the exponential surge of these things would overwhelm not just me, but all of us. I had been taught that the combination of technical knowledge, well-designed and well-practiced process, and collaborative teamwork was the answer. If not, then sleep deprivation, skipping meals, and not going to the bathroom until the shift was over would surely do the trick.
Was I being foolish to believe the unspoken promise of my training and mentors? Had I been sold a naïve myth unsuited for a cynical world?
That birthday night when the overwhelming reality of what was flowing through the ER doors crystallized in my awareness, I was neither a novice doctor nor an entry-level leader. I had chaired our department as we rose on the efforts and ideas of a hundred people from an apathetic culture and subpar quality to a place patients flocked to when they got sick. I was a senior executive in our larger organization as it was on its way to becoming Consumer Reports' number-one safety organization in 2012.
I had been “leadership developed” since high school and would be throughout my entire executive career. I had been tested, tooled, evaluated, lectured, boot camped, accredited, certified, promoted, fed-back, coached, videotaped, and fish-bowled. In response to the question, “What do you want to focus on?” at a leadership institute, I replied that