MARCIA DAY CHILDRESS: Good afternoon.
I'd like to welcome you to today's medical center hour.
I'm Marcia Day Childress from the Center
for Biomedical Ethics and Humanities
here in the medical school, and we're delighted to invite--
to welcome all of you here on what feels like,
I hope, one of the last summer afternoons
right before the start of fall.
What still resonates with you when
you're spent physically, emotionally,
morally, spiritually spent?
If you're a caregiver or a teacher, a leader, a colleague,
someone on the front line in another
of the serving professions, how do you persist and endure
when you feel thoroughly drained?
At such times, what can we offer and do when all else fails,
when all we have left is our humanity?
For all of us in Charlottesville,
recent weeks have asked much of many of us,
our first responders to be sure, our clinicians, our clergy,
our public servants, our teachers, our students,
and others.
And during these same weeks in other parts of the country
and across our world, natural disasters
of historic proportions have burned, blown, flooded, rocked,
sickened, and killed.
Help on site has come from dedicated professionals who
have worked superhuman schedules,
confronted calamitous devastation and loss,
witnessed great suffering, and then worked some more.
How do they do it?
And how can they do it in ways that
enable them to persist and to maintain
some emotional and moral resilient resilience?
What human resources might they yet have available?
We welcome today Tim Cunningham to this medical center hour.
With preparations in both nursing
and the narrative and performing arts,
Tim brings an unusual sort of expertise to this forum.
In this hour, he will weave together
three stories from desperate sights and desperate situations
to inquire into what might matter the most to us
at the most trying times.
A clown and then a nurse and now the director
of the Compassionate Care Initiative
in the School of Nursing and an assistant professor
there but also with a joint appointment
in the University's Department of drama,
Tim will share what he believes matters most
when all else is lost.
And he'll show us how we actually all
have the capacity to access it.
I will mention too, Tim has been here before,
produced a one person play that he had written and acted
something like, I don't know, 20 some parts,
which included him standing on the furniture, which
I don't think he'll do today, but I'm not sure.
He also has declared no financial conflicts of interest
for this program.
And so now Tim Cunningham, and at the end of the hour,
we'll have time for interactions with you.
Although he may involve you earlier too.
Thank you.
Welcome, Tim.
[APPLAUSE]
TIM CUNNINGHAM: Thank you Marcia I learned as a student at UVA
when I was getting my CNL degree at the nursing school, a very
important lesson that I'd like to share before I begin.
I was doing some research in Limpopo province South Africa.
We were working with community members trying
to understand their perceptions of water,
how they used water, what mattered most for them
when it came to water.
And we brought some community members in
to speak with students at the University of Venda,
and this amazing thing happened.
We invited one of the elders from the community to come in,
and she walked up we introduced her and she did this.
And she was an older woman.
And as a nursing student always looking
for the nearest emergency, I thought
she was about to do this.
And I spoke with her afterwards, and I said what is that about?
And she said in our community before we
speak publicly, the first thing we do is we pause
and we take a moment.
And in that moment, we respect the collective wisdom
in the room in front of us.
We respect the wisdom that each individual sitting here
in the audience brings to this discussion, this discourse
today.
And we say to ourselves, oh my god,
who am I to be talking in front of this group of people?
How grateful I am?
So thank you for giving me the chance to speak and share
some stories.
I'd also like to express gratitude
to those mentors of mine who are in the room here
today, people that I'm going to speak about,
those living and those who no longer are living with us.
I do need to start with the disclaimer.
We love disclaimers here.
I have no financial conflicts of interest.
If I did, I probably would've retired by now.
I also do want to make it clear that I am a clown,
and I realized with the release of the new Stephen King It
and on the coulrophobes-- there might be some coulrophobes
in the room--
there will be no clowning today.
So I just want you to know that you're all safe.
You're all fine.
The second disclaimer that I want to put out there
is that every name that I use is a changed name.
I have not gotten permission from the living and the dead
who I'm going to be speaking about,
so all the names that I use are pseudonyms just to let everyone
know.
And the third disclaimer is that I'm not
going to talk about clown.
This has nothing to do with clown,
and I think it has everything to do with clown,
but I'll let you all decide.
The first story takes place in Sierra Leone,
a town called Port Loko.
In January of 2015, I was working with an organization
called Partners in Health.
I was a front line nurse treating Ebola patients.
As a pediatric nurse by training,
I spent most of my time working with pediatric nurses.
And shifts were horrible.
On average, we lost two patients a day.
We had no supplies.
We had a pharmacy that had about nine medications
in the whole pharmacy, and those nine
medications we had to use to treat every condition that
came in.
A little bit of context was that when
Ebola hits Sierra Leone and other parts of West Africa,
hospitals and clinics shut down.
800 plus medical providers, nurses, and physicians
got sick with Ebola working in West Africa.
Roughly 500 of them died from Ebola.
So hospitals and clinics said we can't
run the risk of spreading this disease anymore,
so they're shut down.
As Ebola treatment units opened up,
we had to screen every single patient that
came to us to first see if they had Ebola or not.
If we deem them negative for Ebola,
we had a checklist with 10 questions.
If they met the criteria by saying yes to three of the 10,
we brought them into our treatment unit.
If they didn't meet criteria, we stripped them naked,
took everything they brought into the treatment unit,
wash them in bleach and soap and water and sent them home.
But the patients that came in who met criteria,
we brought them in, we drew their blood,
we sent their blood to the local lab,
and it took two to four days to get lab results back.
Another piece of context I want to share
is that in the US if we are suspecting Ebola,
we draw your blood and within four hours
we can have the results.
A little more context, I was working about three hours
outside of Freetown, Sierra Leone,
and there was a clinic set up for expats.
People from other countries who came to do the work,
they had a portable lab, and in their lab
they could run tests within four hours.
But the majority of those who were sick and at risk of dying
had to wait two to four days in our treatment unit.
About a quarter of the patients that I worked with that
died, died of conditions other than Ebola.
We had nine medication to treat everything, no oxygen,
no insulin, no albuter--
run the list.
We had very limited supplies.
So January 2015, this is a map--
this is an image from a children's book
that I'm working on about resiliency and about the Ebola
epidemic.
I want to start by telling about three very important people I
met that night in July.
Coming into triage, we had one elderly man arrive,
and he looked great.
We saw some patients that looked horrible.
We saw some patients that arrived to us dead.
This man looked amazing, and he had my father's eyes.
He was my father's age, and I looked at him
as he sat in a chair and I said, here are your supplies.
He had a fever.
He had been at a funeral, and he had some nausea.
So he met criteria to be treated in our Ebola treatment unit.
I looked him in the eye, and I said you look good.
Here's some fluids.
I'm going to give you an IV.
We're going to hydrate you like crazy,
and I want you to drink or die.
Literally, you will drink or you will
die, because the only cure for a Ebola--
the only treatment is hydration and maintaining hydration.
And he looked me in the eye, and he said, yes sir.
And I walked him back to a room, and I
thought this guy-- he's going to be one of our survivors.
Were going to celebrate him in a couple of weeks
when he clears Ebola.
There was that gentleman.
There was a nurse we were treating.
She was 22 years old, and she was horribly ill.
Her blood results had gotten lost,
so she was in our suspect ward for four days.
Her results were lost in the lab.
I mean, we were literally taking and handwriting
patients names on these tubes.
That's all we had.
Her results were lost, so we had to draw again.
She was becoming encephalopathic,
which means she literally lost her mind,
and that usually worked or happened with patients
two or three days before they died.
Her eyes sort of started to bulge out of her head.
We called it the wide eyed stare.
And though we had limited diagnostics, when
we saw the wide eyed stare we knew that the patient only
had maybe hours left to live.
She was a nurse.
She got Ebola by treating and saving other people's lives,
and she was dying alone encephalopathic.
And she was a fighter.
She did not like it when I started IVs
and when I gave her medications.
She was always taking care of others in the room around her
before she got very sick before herself.
She was a nurse.
I think we can relate.
So we wanted to take care of her and make sure that she
had a good death that night.
And then the third patient that I want to speak about
was a woman named Kadiatu.
Kadiatu was 24 years old.
She came to us 26 weeks pregnant.
She was eclamptic.
We-- the ambulance that she was brought
in backed into our triage.
We sprayed the ambulance with bleach,
which is what we normally did.
We opened the ambulance, and there she
was convulsing on the floor of the ambulance.
We brought her out.
We gave her Valium, which was the only medication
we had to treat convulsions.
And then we called the local hospital and said,
please, please, please we will give anything
for some magnesium.
After hours long discussion with the hospital down the road,
we were able to get enough IM doses of magnesium
that we could treat her 5 milligrams every four hours
at least until she died.
Our goal was to keep the seizures under control.
That was the beginning of my shift that day.
We had 70 other patients that we were
treating in the treatment unit.
We had two nurses.
We had three sprayers, people who would spray everything
with bleach, and we had a couple other technicians who
would help us move patients.
Went into work, said this is what we're going to do,
these are the three people that I'm really
thinking about I want to prioritize,
and then the power went out.
Everything shut down.
We had a rule at our Ebola treatment center
that if there's no electricity, you
do not go into the treatment center,
because it is so dangerous.
You'll trip.
There are exposed nails.
There were a lot of hazards.
And so I spent the whole night shift
standing outside of the fence listening to people
actively die, because we could not go in.
Why did we not have power that night?
Because a community member needed gasoline
to fuel their car or their generator at home.
We couldn't get enough fuel to keep the electricity going
to treat one of the hottest zones in the world at the time,
whereas here in the US we had stockpiles of supplies
at all the major airports, all the major hospitals.
To learn about the great differences in preparation
and supplies, we didn't have enough supplies
to at least give compassionate deaths to our patients.
We literally had nothing.
I went to sleep.
I woke up when the sun came in that morning.
And when I have--
when I'm challenged by something that I
don't know how to manage, when I don't
know how I'm going to go back to work, I turn to poetry.
I left my shift, and I picked up this Whitman book
that my sister had sent with me.
She said read about Whitman.
And I missed Virginia at that time,
so I looked for a poem that mentioned Virginia.
And I found a poem that said, as toilsome
I wandered Virginia's woods.
And I thought, oh, that sounds fancy.
I'll read that and fall asleep and get ready
for the next night shift.
But right above the poem, another poem stuck out,
and I want to read that right now,
because this was my experience.
"A sight in the camp in the daybreak gray and dim.
A sight in camp in the daybreak gray and dim as from my tent
I emerge so early sleepless.
As slow I walk in the cool, fresh air, the path
nearby the hospital tent.
Three forms I see on stretchers lying
brought out there untended lying.
Over each the blanket spread, ample brownish, woolen blanket,
gray and heavy blanket folding, covering all.
Curious, I halt in silent stand.
Then with light fingers I from the face of the nearest,
the first just lift the blanket.
Who are you elderly man, so gaunt
and grim with well grayed hair and flesh all sunken
about the eyes?
Who are you my dear comrad.
Then to the second, I step.
And who are you my child and darling?
Who were you sweet boy with cheeks yet blooming?
Then to the third, a face nor child, nor old, very calm
as a beautiful yellow white ivory.
Young man I think I know you.
I think this face is the face of the Christ himself,
dead and divine and brother of all and here again he lies.
Suffering is not unique.
Whitman wrote about suffering he witnessed while working
as a medic in the war.
I worked with soldiers and veterans
in the Ebola crisis who had served
in other wars, many of whom said this was far worse than working
in war, because we couldn't see the bullets.
We couldn't see the aggressor.
We knew every day in just touching our patients
we were exposed to Ebola.
Suffering persists.
Today, I want to talk about some tools
that I've learned from the people
that I've worked with and treated
on how we can look at that suffering no matter what.
No matter that we have nothing, because we will all
face a time if we have not already
when we literally have nothing.
But there are tools that we do have.
I like to put this map up when I talk about Ebola just to remind
people that Africa is a very large continent with 54
countries, even though the media said Ebola is in Africa.
When I come back and I talk about this,
people say, oh, what language you speak?
Do you speak African.
The othering that took place during the Ebola epidemic
I would argue cost lives.
A land mass roughly the size of California and Oregon
was where the heaviest caseload was,
although the resource rich world was stocking up supplies
just in case one case got here, one case got there.
By our own protection and defense, we cost lives.
And while lives were being lost, I
learned some of the most important lessons
I've ever learned.
I'm going to speak to you about a child named Mobinty.
Mobinty was eight years old.
Mobinty came to us in the back of an ambulance
with her 10-year-old brother.
Both their parents had died of Ebola,
and the local chief had found them alone in their home
and called-- there was a number.
It was 117 just like 911.
The chief called the number and said
we have two kids who I think are sick.
They were put in an ambulance.
They were on a-- they were driven hours away from home.
And when they arrived to us, we sprayed down the doors.
We open the doors.
Mobinty and brother were both very sick.
They had vomited.
There was diarrhea in the ambulance.
And when we saw a child that sick,
our first goal was to get them hydrated.
We thought it was very likely they would have Ebola,
so let's start hydration.
This is an image not of Mobinty.
This was given to me by Partners in Health
of the team members trying to start
an IV on a writhing, angry, horribly afraid child.
So we start treating the children,
and Mobinty and her brother were great patients.
We brought them into our suspect ward.
We drew their blood.
When their blood came back positive for Ebola,
we immediately sent them to our confirmed ward,
so they could be surrounded by other Ebola patients
and we could give them intensive care.
This is what they saw every day.
This is a photograph of our Ebola
training run by the military.
Ghosts, beasts, monsters is what we were.
Dressed in white from head to toe.
Dressed in yellow from head to toe.
Sometimes dressed in green.
The only thing that our patients could see
were our eyes, the only thing.
Inside of the suits, it got up to about 130 degrees.
When we finished doing our work and doffed our suits, which
were covered viable by the time we finished treating patients,
we would sit and hydrate with about six or seven liters
of water and Gatorade every day just
so we could go back in and spend another couple
hours wearing these suits.
This is what Mobinty and her brother saw her every day.
As a peds nurse, it was my job to encourage
her to eat, to drink, to not throw up,
and to move around, because we found
that patients that moved more were more likely to survive.
Mobinty hated me.
And as I treated her more and more,
she got better and better and her brother
got progressively more ill.
It got to the point where he couldn't move,
but he was always telling her to eat and accept the drugs.
She laid next to him on a cot, and they would hold hands.
And we would come in and treat the two,
and Mobinty would see the needles.
I'd have to give her im ceftriaxone.
And she would see the needle, and she would start
trying to get out of the way.
And her brother with all his strength would hold her hand
and look at her and say sit still, and she did.
When we brought food to the two of them,
he refused to eat until she had already eaten half of her tray.
The day that her brother died, we lost three other children.
It was a horrible, horrible day.
And I went in the evening shift--
I wasn't there when he died.
And I went in the evening shift, and I saw Mobinty,
and she sat up in bed and she stormed right to me
and got up in my face and pulled out a children's book.
And she grabbed my hand and she took me right out the ETU
and sat down and pointed at it and asked me to read
this children's book to her.
I had never seen such fire in this child
or any of the patients that I had treated.
It's as if when her brother died,
he transferred the remaining living
energy that he had into her and she got better each day.
She stayed outside of the ward every day,
and as practitioners came by, she
singled out certain practitioners
and made us read the book to her and made us give her food.
And she was able to go home a couple of weeks later.
So this is where I'm getting with this story.
When Mobinty left and we were able to take her out
of the treatment unit, when we gave her new clothes, when
we washed her down from head to toe,
she went to the front of the unit and waited for a bus
to pick her up to take her home.
Often we would go out front to meet the survivors,
because that was the only time they didn't
see us looking like this.
That was the only time they didn't hear our voices--
I mean, we sounded like Darth Vader.
It was disgusting.
It was grotesque.
It was horrific.
And so we'd go out to see the survivors.
And I went out with the team.
And we had a couple of huggers in the team.
We had some huggers in the group even though we weren't
supposed to touch and hug.
And we had some people that were very callous until they
saw a really sweet child, and then they totally melted.
We all had different attitudes toward the survivors.
We walked out, and Mobinty saw us and she charged at me
and gave me a hug that felt like it lasted 10 minutes.
She saw one of the other pediatricians
and went directly to him and did the exact same thing.
And we had a couple other docs in the group who were big hug--
big huggers, and they needed the hugs to refuel.
And so some of the other docs were like, oh, Mobinty,
and she just went right by them, right by.
They got nothing.
And then me and the other provider were just like yeah.
But we realized in that moment Mobinty,
despite the fact we were completely covered head to toe,
knew who we were.
She knew our presence.
And I think I would argue that's the first thing that as nurses,
as physicians, as teachers, as providers, as humans, no matter
where you are so long as you're living,
you have a presence from the top of your head
to the tips of your toes.
And if you can live and work and express yourself in that way
no matter what the situation is, if you can enter
this space with that presence, you've
already got to step up in a completely dire situation.
Mobinty was eight years old, and she
knew every inch of our bodies.
She could understand that presence.
We're here right now.
We have these instruments.
As an actor, I was always trained use your instrument,
know your instrument, play with your instrument.
So I want to talk a little bit about our instruments.
Is anyone familiar with the idea of sympathetic resonance
or emotional resonance?
Imagine you have an orchestra full of instruments,
and there's no one sitting by the instruments.
They're all just sitting there lined up,
so you've got an image like this, but there are no people.
If someone comes out on a violin--
and you have to put a device on every string
on all the instruments that measures movement, OK.
So you've got this experiment set up.
If you-- if someone walks into the space and takes the violin
and plays an A string-- is there an A string on a violin?
OK, good.
So someone plays the A strong on the violin--
I know cellos, but not violin--
all the other strings will begin to vibrate.
Strings that match that registry will begin to vibrate,
and you can measure that vibration.
Sympathetic resonance, emotional resonance, Ron Epstein
talks about that work in a recently published paper.
What is your emotional resonance?
When you look at a piece of art and you get the chills,
what is that?
When you read a poem and all of a sudden everything
seems to fit, what is that?
As a nurse walking into a patient's room who
is scared to death and they look at you and they relax,
what is that?
That's your presence.
That's how you can resonate with other people.
It's not easy to do.
It's really hard to measure.
But I want to give it a try.
If everybody, kind of, sitting for a second,
if you could just repeat after me.
[SOUND] I love it.
People start laughing right away.
Laughter so fascinating, isn't it.
It just bubbles up, and people laugh for all sorts of reasons.
We can't control it.
[SOUND] Gain about 80 pounds right now.
[SOUND] Good.
[SOUND] Feel it in your belly.
Now in your chest.
[SOUND] Feel that vibration in your chest.
[SOUND] It feels good.
It's OK to do it.
It's OK.
Now the upper register go [SOUND]..
How ya'll feeling?
We OK?
AUDIENCE: Yeah.
TIM CUNNINGHAM: OK, good.
We've got more to do.
The next story takes place in Haiti.
In rural Haiti, this is the only image
of clowns you're going to see.
If I need to blank the screen, just raise your hand.
I'll blank the screen.
I was working in Haiti in 2011 just
after the earthquake that basically destroyed
the country, and we were working with a group of children.
We were asked as clowns to come perform for these kids
and also do workshops with the children on acting and playing.
And they wanted-- the NGO's we worked
with were interested in seeing if we could work with the kids
to help them feel comfortable going back into their home.
Kids were still sleeping on the streets, in tents.
There were-- there were tremendous aftershakes that
lasted a year after the earthquake.
And we wanted to, sort of, bring this out with the kids.
So we developed a bunch of different activities and things
like that, and we realized one important thing
that was missing.
As a patient, what happens to you when you go to a hospital?
You go into the emergency room.
What happens?
AUDIENCE: Take your clothes off.
TIM CUNNINGHAM: Take your clothes off.
What else happens?
Thank you.
AUDIENCE: Questions.
TIM CUNNINGHAM: Questions, rather impersonal questions,
and then really personal questions.
What else happens?
Touching.
Turn off your cell phone.
Stop looking at that.
We literally take everything away from our patients
when they come.
We physically strip them, we emotionally strip them,
because we need to get the diagnosis as rapidly as
possible so we can move on to the next patient.
When I was working with these kiddos in Haiti, and this was--
I guess I had been a nurse at that point.
I realized that these children had
been stripped of many similar things,
and one key factor is that they were stripped from their names.
Those of you who are providers, how many times have you've
forgotten your patient's name and you just mindlessly
refer to them as asthmatic in room 75?
Whether you mean to or not, we get so
wrapped up in what's going on we forget
the names of our patients.
So we did an activity with these kids,
because we were playing with the kids.
They liked playing, but they didn't like it when we actually
did structured activities.
And they were very tepid and very cold.
And so I asked one of the children where the ocean is.
Does anybody know where the ocean is?
Like here in Virginia, which way is the ocean?
East, which is?
I need fingers.
I'm bad with directions.
I see some fingers--
OK.
We are-- we are-- we are--
OK, I see the majority of fingers are going this way,
and I see one finger that way.
So let's go this way.
So I asked the children to throw their names into the ocean.
And the first response was, and I thought well maybe
my creole was bad.
So I asked one of the youth leaders
I was working with to translate, and he
translated the exact same way, throw your name into the ocean.
And we work with the kids for about half an hour
to the point where we wanted them to, like, say their name
and throw it all the way into the ocean.
And it started with kids not wanting to move very much,
and it ended with this.
After about 20 minutes of a child--
I'll be the child--
saying their name to themselves--
Tim-- looking at the ocean, and then throwing.
Tim.
Did you see it go into the ocean?
Did you see it go over the ocean maybe?
So some of the kids started throwing their names
over the ocean.
It was a silly game.
I've done it with some students.
Students are often as awkward when we get going.
But then after playing that game,
we could not hold these kids back.
They were proudly saying their names.
They were sharing their names to other community
members that walked by.
They were playing with a sense of ferocity-- these children
who had lost everything, playing with a sense of ferocity
as if they were the richest, wealthiest, most
spoiled kids who had everything in the world.
These kids were playing at this top level,
because they were able to share their names after hearing
their names.
You have your presence, and you have your name.
So long as you're living, you have your name.
And I think part of the human condition
is understanding where our names come from
and what that means to build towards our presence,
so that when we come into a room, when we care
for patients, we can be seen as who we are,
whether we have the supplies or not.
I'd rather be treated by a human being who
needs to run back and get a few supplies versus a machine who's
got all their gear and just starts to cut.
Know your presence.
Know your name.
This third story takes us to the US.
It's very fun to talk about adventures and people
that I've met in other countries,
but so much of that is happening here.
This is a story about Brian.
Brian was a 13-year-old child.
He was diagnosed with Neuroblastoma
when he was at a relatively young age.
I was working at the emergency department
in a hospital on the Upper East Side,
and Brian had basically been sick all of his life.
And he was from Florida.
His mom took him to the oncologist just one day,
and his oncologist basically said there's really nothing
else we can do for Brian.
He's getting progressively sicker.
We've tried everything.
We can't get him on a study right now.
Enjoy the last days, perhaps months
that you have with your child.
And his mom ferocious as a lion would not
take that as an answer.
As a pediatric nurse, I've been more--
I've been-- I've seen guns.
I've been held up at knife point.
I've been assaulted working as a nurse before,
but I think my biggest fear is a mother who
is not getting her way.
Because mothers will do anything, anything,
anything to protect their children,
and I so deeply admire that.
I so deeply admire that.
So she wouldn't take no for an answer.
They had been seen once at Sloan Kettering Memorial
Hospital up in New York, and they
had some family in New Jersey.
So mom said, OK.
OK, oncologist, nice knowing you.
I'm going to take him up to New Jersey
to visit family, because the oncologist also said,
don't travel with him.
He's a little too sick.
Don't travel with him.
She said, he needs to see his family in New Jersey.
I'm going to take him up there.
Little did the oncologist know that she was actually
going to take him directly to Memorial Sloan Kettering.
Literally once they got off the plane at LaGuardia,
she got him in a cab, and they went
to Memorial Sloan Kettering.
Went to the front door, and they said, who are you?
She gave the patient's name, and they said
you're not a patient of ours.
She said, no, I was seen a long time ago.
They said, we may have done a consult,
but we didn't follow you, so we can't treat you.
Ever creative, ever resourceful mom
said then what will you do for me right now?
And the physician who I don't know,
who I still need to thank, put their son in a wheelchair
and rolled him literally across the street
to the emergency room where I was
working in the pediatric emergency department.
And when Brian arrived, Brian was gray.
He was sitting up.
He was awake, but he was gray and was
in excruciating back pain.
We saw him.
He was septic.
We brought him back to a room.
I immediately started the work up.
We got labs.
We got cultures.
We got fluids rolling, and all Brian wanted was pain med.
I need the pain med.
I need the pain wed--
pain med.
Communicated with the team, got some orders for morphine.
I knew it wouldn't be enough.
This kid's been on morphine for almost a decade.
So I pulled some extra morphine knowing that I would just
sit here and I would just keep pushing it,
we'll get Brian comfortable.
So we're working on Brian.
We're calling the teams, alerting the PICU,
alerting the oncology team, and I give a small dose of morphine
and Brian's eyes roll in the back of his head
and he lays back.
And I step out, and his mom is with him,
so I know if she needs anything she'll holler.
And she yelled, Tim, come in here.
So I turn around, and I go back in.
His eyes are, kind of, rolled back.
And he kind of looked like patients
that I've given morphine to before that just
want a really good fix, right.
You give them morphine, the dilaudid,
and they're like, ah, yeah.
So that's what it, kind of, looked like to me.
Knowing that he really needed pain meds,
maybe he's just relaxing.
And his mom said, he's never done this before
and that worried me.
So I, kind of--
I did a little sternal rub and he opened his eyes,
and I said Brian are you OK?
And he looked at his mom and he looked at me and he said,
I just need to know that I'm still here right now.
And I said, what do you mean, Brian?
He said, I just-- am I still in this room.
I said, yeah, you're right here.
You're in the hospital room.
We just turned off SpongeBob SquarePants Pants,
because you thought that was, like, a dumb, dumb episode.
Here's what's going on.
I just gave you some pain medicine.
I've got some more if you need it.
Do you need more pain medicine.
How's your pain?
And he looked at his mom, and he said,
can she get in bed with me?
I said, OK, we can arrange that.
From that moment forward for the remaining five minutes
of his life, all he asked for was having his mom
at his side in bed with him.
Didn't complain of pain, had no complaints.
As his oxygen saturation started to go down,
he was in the mid 80s.
We moved him into our resuscitation room,
and we started getting nervous.
Mom, picked up on it.
She was asking me, Tim, what's happening?
What's going on?
More team members are coming into the room,
and then Brian sits up at one point and he looks around
and he says can someone please tell me what's happening?
I can't breath.
And he lays back on the stretcher.
Within 30 seconds, we started doing compressions.
We ran a code with Brian for about two hours.
We had multiple teams come in the room.
Those of you who have run codes before, been members of codes,
you know the chaos that ensues when you're trying
to desperately save a life.
And I would say that's heightened,
based on my experience, when you have a child who's
life you're trying to save.
We did everything we could.
Working, working, working, working, working,
we got Brian's dad on the phone in Florida.
And for some reason the phone was handed to me,
and I think I know why.
I get to it in a second.
And I was speaking with him, and I was trying
to explain what was going on.
And I said, sir, do you have anything
you need to say to your son?
Because if you do, you need to say it right now.
And his dad said, yeah.
So in the midst of this code, of accessing the central line,
of running drips, hanging drips, doing compressions,
I get down, kind of, crouching down,
and I hold this phone to Brian's ear for about 15 minutes
while his dad says what he needs to say.
I take the phone away.
I give it back to his mom.
His mom passes out.
She's at the foot of the bed.
We know that family presence in code situations, more and more
the research tells us this-- it's often appropriate.
So we get mom some oxygen. We put her in a wheelchair.
She's not leaving.
The code ensues.
And I realize that throughout the code,
she's been calling my name.
Tim, tell me what's going on.
Tim, fix this.
Tim, why is this happening?
Tim, where is this?
What is this?
What's happening?
All these questions directly to me, and after a while,
I was not running the code.
I started it.
We had the PICU attending down there.
We had our team.
It was actually a relatively well run code
with a very clear hierarchy of leadership,
but mom had no idea, so she had to keep going back to me.
Tim, tell me.
We called the code.
We turned off the monitors.
We sat with mom for a long time.
We sat with the team as long as we
could before we had to go back out
and treat the rest of the patients in the ED.
And after speaking with some teammates afterwards,
I realized that the only name the mom remembered was mine.
Now I'm not going to go and say I was the only care provider
who actually introduced myself.
I don't think that was true.
But as things got busier and more and more hectic,
our own names sort of disappeared.
I doubt very few of the providers
actually knew Brian's real name or his mom's name.
When all else fails, you have a name
and your patients have a name.
And when all is lost--
his mom lost everything that day--
she was able to hold on to my name and her son's name
who she wailed at the top of her lungs in our chapel,
in our emergency room, and down the hall as she went home.
Never lose that.
Never lose sight of that idea that you have a name,
that your patients have a name, and you can always
go back on that.
It's absolutely essential.
So you have your presence.
You have your name.
You have your patient's name that builds the presence.
And last, but not least, far from least,
I want to share a story that's been inspiring me for the last,
I guess, five weeks now.
I have a Dear Colleague with whom
I worked in Sierra Leone treating Ebola patients who
is now working at a hospital in Kabul, Afghanistan.
At her hospital, she stays in a dorm
directly across the street from the hospital.
So when she wakes up in the morning to start her shift,
there's a full security brigade that picks her up at her dorm
and literally takes her across the street to the hospital.
And at the end of the working day, the security brigade--
I mean these are armed vehicles, soldiers with big weapons,
taking then-- the staff back across the street,
because it is so dangerous there right now.
A war that we started 16 years ago
is picking up again and ravaging.
She's a pediatric trauma nurse.
They have very limited supplies.
I would say they have more supplies
than we had in Sierra Leone.
They have very limited supplies.
She's working with an NGO called emergency.
One thing that she has found that has worked wonders
for her patients is this.
Can everyone-- can everyone see what this is?
Oh, no.
Let's get rid of that screen there.
A rubber chicken.
As I said, I'm a clown.
And I spent some time with my friend before she left,
and I gave her a chicken.
I said keep this in your pocket and just carry it around
with you.
It's a little reminder that we love you and we care about you
and we're thinking about you.
So she started doing that and carrying it around
in her scrubs, and she-- kids started grabbing it,
playing with it.
So now she's got one pocket full of alcohol wipes, and one
pocket of rubber chicken, so clean in between patients,
moving it around.
It got to the point where kids started stealing the chicken,
hiding it.
There was a fountain in the courtyard in the back,
and she would find the chicken swimming sometimes
through the courtyard.
And then at one point it disappeared,
and the kids were, like, we don't have it.
And she said someone's lying to me.
Someone's hiding this chicken.
Turns out the surgery team stole the chicken
and were doing procedures on the chicken,
placing different bolts and screws and nuts and things
like that, and then the chicken disappeared.
We hope it went home with a child that was
discharged after they survived.
We're not sure.
So she e-mailed me, and I sent her a box of 50 chickens.
So she has many more chickens right now,
and just sent a request for another box.
So I think there are like 100 chickens
there at this emergency hospital in Kabul.
This is a photograph that she sent to me that I
think sums everything up.
This is an image of a child who is playing with his friends,
found a landmine who no longer has
his arms, who has a mangled left leg and foot,
but can do anything and everything with his right foot.
And he spends his days pulling at, snapping,
throwing this rubber chicken around the word.
It's not about rubber chickens.
I wish it was.
I'd have a lot more work that way.
But ultimately it's about creativity,
and the creativity that you bring to your profession.
The creativity that sometimes breaks the rules,
if it's not causing harm.
I'm currently running a focus group with the Compassionate
Care Initiative, and we've had some very interesting
discussions about compassion and what compassion is and how
can you-- how can you-- if you see something happening,
can you say that's compassion?
Can you, sort of, put it in a box?
And we're not sure that you can.
I kind of hope that you can't.
But one thing that keeps arising in these focus groups
is this absolute creativity when there's nothing left, what
do you still have?
I'd love to leave you with that idea
that we all have inherent creativity.
Some people say, well, I'm not an artist.
That's why I'm in Med school.
I'm not an artist.
That's why I'm in nursing school.
I think the best artists are nurses and physicians,
because they can manage this world of the abstract
and the world of the concrete and bring the pieces together,
so that they can be present and connect
with their patients and the patients' families
and provide the highest level of quality care.
So what is your creativity?
Where do you find your creativity?
And how does that creativity from your name
build towards your presence that changes every day, which
is great about it?
We're always evolving, always changing,
but how can you follow that and know that,
so that when you step into a patient's room,
when you step into a situation that you can just not handle,
you can just be there and you can
provide the best care possible?
I think of the words of Danielle Oliver who
spoke last week at medical center rounds,
and as I was putting this talk together,
I kept going back to them.
Very simply she said, keep showing up
and keep being present.
To honor her words, I'd like to repeat that, keep showing up
and keep being present, and I would like to add,
add a dose of creativity and you'll be able to manage.
Thank you all so much for coming today, for listening.
I think we have some time for some questions
if anyone has any questions, comments, threats, warnings,
dissertations.
We have some mics floating around.
MARCIA DAY CHILDRESS: Thank you.
TIM CUNNINGHAM: Thank you.
MARCIA DAY CHILDRESS: Thanks.
As Tim indicated, we have a generous amount
of time for some interaction with you.
And I think for one thing, if in this beautiful and moving
presentation, if he sat us all resonating sympathetically
with him but also with each other
and with the kinds of perhaps remembered situations
that we've been in where we have needed these kinds of basics
that he has mentioned, how can we work together
in the next few minutes to think out loud about what it is
we're doing, the work we're doing,
the work we're called to do, the work that's hard to do?
And what kinds of questions do you have for Tim
that maybe, kind of, rudimentary practical things like where
do I get a chicken or maybe a deeper, sort of,
more metaphysical question, how do I
find time to discover my sense of presence, things like that?
So when you have a comment or question,
please do identify yourself, and then we'll
have several minutes of conversation
with this remarkable guy.
So who'd like to start?
And John, there's a question up there.
All the way up at the top.
AUDIENCE: Thanks so much.
I'm Justin Mutter from The Center for Biomedical Ethics
and Humanities.
And I'm a geriatrician here, so--
and presence and naming is something
that I think about a lot in my work
with families and with older patients.
And one thing that struck me and I'm curious your thoughts
on it, you mentioned breaking the rules,
which I like that idea.
But it's challenging, of course, to do that,
and I want to contrast that vision with,
well, let's just call it the technocratic vision
of medicine, right, that we follow these procedures.
We have set appointment times.
We do all these things in a very algorithmic way.
So how do we navigate that divide, because it is a divide?
And how do we do that meaningfully and break
the rules appropriately?
TIM CUNNINGHAM: Yeah, thanks Justin.
It's extra hard when you think about rule-breaking
in medical and nursing care, because you could cost someone
their life.
One piece that I think of and when I speak with students
is that in order to break the rules,
you have to know the rules very, very well.
And so the first step towards breaking the rules--
if you think of Picasso and some of his very abstract pieces,
if you look at his early work, he
was a very, very fine technician.
So train, know the rules, work with the rules,
live in that world for a while, and then start to branch out.
So I think that's one aspect.
I think another is noticing when the rules are broken,
and you might not even call it breaking the rules.
I spoke with a nurse recently who
talked about a patient who died, and the nurse
wanted to do the patient's hair before the family came
in and fixed the patient's hair and the family came in.
And when the family reflected on their hospital experience,
that's what they kept going-- kept going back to.
And they had been in the hospital
for a really long time, but the fact that the nurse did
the patients hair.
Now, that didn't cause harm, but I
would argue that might be breaking of the rules,
because as a nurse working the ICU, that's
the last thing I have time to do,
because I have other patients to tend to.
And other things were put off, because this nurse
needed to do the patients hair.
So I think also learning the rules really well,
and then noticing the slight breaks and, sort of,
growing off of those and then celebrating that.
When you have colleagues that break the rules,
celebrate that.
I worked with a colleague who would
like to put Gatorade in urinals in the ER sometimes.
Many of you probably know this colleague,
and it worked sometimes and patients loved it.
And then another time this colleague
got in a lot of trouble for it.
So it's always a fine line.
But I think as learners, especially, learn the rules
first and foremost.
And then I tell my learners when we're in the classroom setting,
this is the Petri dish where I want
all the experiments to fail.
Because it's much safer that you fail in my classroom,
then you fail on the unit interacting with human beings
that need your care.
So let's try something new.
Let's talk through new ideas, and let's see
how that is bending or breaking the rules.
MARCIA DAY CHILDRESS: Just also to follow up
on that working with practitioners
in that way and students, do you also
envision working with leaders that way,
so that they know that people have
had the kind of preparation where rule-breaking may occur
for all the right reasons?
TIM CUNNINGHAM: Yeah, thanks Marcia.
I think in that form it's how do you
change the language around it, so that leaders recognized
this is what we're trying to do, this is what's going on,
this is why it's important?
And I think we see a lot of change that
happens from the bottom up.
But I think sometimes when you change language--
if you can change language from the top down,
so everybody's talking about this idea of what
is this sense of rule-breaking?
What is this sense of looking at things differently?
If the leaders are talking about it,
then I think there's much more permission with that.
Narrative medicine is another great approach.
When working with practitioners, providers
who have been in the field for years and years
and years who they can't remember when they were last
in school, when you work in narrative medicine setting
where you're writing, you're sharing ideas,
you're critiquing ideas, you can also
frame that as a great place to fail.
So maybe it's practicing failure,
and for those of us that are making life changing decisions,
where can we fail and let's fail as best we can in those places,
so we can go back and see how those experiments work out.
AUDIENCE: My name is Michael Swanberg.
I'm at the School of Nursing.
And I think I know that colleague who's putting
the Gatorade in the urinal.
But as director of the Contemplative Care Initiative,
can you share some examples of nurses who
are doing this creative work?
TIM CUNNINGHAM: The creative work, sure.
AUDIENCE: Yeah, at the hospital.
TIM CUNNINGHAM: Thank you, Michail.
And so-- and to clarify Compassionate Care Initiative,
we--
with the Compassionate Care Initiative,
we have a group of ambassadors, clinical and faculty
ambassadors that are working throughout the hospital
and at the School of Nursing to help relieve stress,
to help recognize and support people in what they're doing.
One of the small rule breaks we have--
I mean, we have a compassion cart that
rolls through the hospital.
It's led by a nurse by Carol whose last name is slipping me.
I'll remember when I get home.
Carol takes the cart to the hospital.
It's full of snacks.
It's full of goodies.
I think occasionally it has bubbles
on units where you can't necessarily always have food.
She finds ways to, kind of, smuggle it in.
Clowns-- now, I know there's been
some issues with the clowns at the hospital here,
which I've been addressing with volunteer services.
But you often see clowns in larger pediatric hospitals that
are toilet papering rooms, having water fights in places
where it's appropriate, lots of rule-breaking going on there.
We also-- I guess you could consider rule-breaking,
we have people that will lead brief yoga practices
during the middle of a shift or brief mindfulness meditation
practices.
Hey, do you have five minutes?
Come over here.
So rule-breaking in that we're breaking the norm, breaking
the regular schedules, and in those breaks,
we give our chances for-- we give a chance for our minds
to change.
And we know that with changed minds
we think differently and can maybe provide better care.
AUDIENCE: Hi, my name is Lydia Whitman.
I manage the patient and family library in the hospital,
so I'm a librarian, but I've been in the hospital setting
for about 15 years.
I think what I want to share, though,
is more from my experience as a care partner
to a very sick person.
In the hospital as a care partner,
very different experience from being a staff person.
And the nurse there was some bad news that I had to get,
and the nurse instead of staying in her professional role really
connected with a personal story that was similar.
She said when I got this bad, I. And I don't
know if that's rule-breaking.
I don't know what you learn in nursing school,
how it's probably impossible to say what that boundary--
when it's appropriate.
But I think it was really her humanity.
She was connecting with me as a human being
who's getting bad news.
And that-- I wish I remembered her name.
I don't remember her name, but what I remember
is that I felt really cared for, and that was compassionate
to me, because I was having trouble with this new.
So, and that's here in a third--
not third world-- here in this setting,
we have all these resources.
But I was stripped down--
I was feeling stripped down to nothing,
and she was able to meet me there.
So I don't know.
I guess it's not a question.
I just wanted say that was really powerful for me.
TIM CUNNINGHAM: Yeah, thank you, Lydia.
Thank you for sharing it.
And that's a beautiful story, because in nursing training
we are trained to have boundaries.
And I think you could argue that some rule
breaks are when boundaries are broken and lines are crossed.
And I've heard from some people don't
cry in front of the patients and others,
it's OK to cry in front of the patients.
Some people say don't bring your personal life to work,
and others say do, but do it so in a sense technically.
I would think that maybe the nurse was almost being
as much a technician as a human in that moment,
knowing that this is how we can connect,
so I'm going to give this to you.
As nurses and physicians we have to be careful, though,
because if we give that out, then when we go home
we're completely empty.
And that's part of the work we do with the Compassionate Care
Initiative as well is how do we recognize those lines
and blur them?
I think in this case blurring lines are
essential to good patient care.
Don't quote me on that.
I'll get in trouble--
or do.
AUDIENCE: Thanks for your talk to them
and teaching everyone how to avoid
PowerPoint among other lessons [INAUDIBLE]..
And the Dalai Lama also teaches know all the rules,
so you know which ones to break.
And I want to thank the School of Nursing
not only for the Compassionate Care initiative and for Tim,
but for the first official therapy dog.
And I'd like to issue an invitation to Barringer Five
to our center to come and visit.
TIM CUNNINGHAM: Yeah, what's--
Kenny.
Kenny's the therapy dog's name.
Thanks for saying that, Denny.
Yeah, we need more dogs.
And that's rule bending for sure, I think.
Yeah.
AUDIENCE: Trained hypoallergenic dogs.
TIM CUNNINGHAM: Yes, very well trained.
Yeah.
MARCIA DAY CHILDRESS: I think also just
to get back also to what was very
early in your presentation, the comments about the importance
of presence and naming.
One of the things that seems to me and it connects
with your experience as a care partner
as well is that sense of being known when you're a patient.
But also I think part of your presentation tells us
it's important to be known when you're a caregiver as well,
that there is that, kind of, recognition that's exchanged
between two people who are, kind of,
stripped down to just their essential humanity.
When that is still present and when that kind of recognition
can occur and when you know sometimes
laughter can bubble up like those noises
you got us to make--
TIM CUNNINGHAM: Yeah.
Yeah.
MARCIA DAY CHILDRESS: --and resonate with each other
it becomes pretty important.
We did a writing exercise with some medical students,
fourth year medical students a couple of years
ago in which they were asked to write
for five minutes about an instance when they were being--
when they were being cared for, when they were ill
and being cared for.
And then they read those accounts to each other.
And it was interesting.
Out of, I think, the 11 students in the room, 10
were cared for by a parent and one
was cared for by a physician.
There were nine moms, one dad, and one anesthesiologist.
But when we talked about this, it
turned out the bottom line thing that mattered most
to these students when they themselves were patients
was the sense that the person caring for them
knew them in a very deep and elemental way.
And I hope that they carry that memory with them
into their work with patients.
Some of these illnesses were when they were like four.
One student had been sick with the flu earlier that year,
and his dad had taken care him.
So these were long ago and recent,
but it was important to, kind of, turn the tables.
TIM CUNNINGHAM: You know that makes me think
and recognizing that you matter as a provider
and your interconnectivity, I think about the--
there's Charles Bukowski book titled
What Matters Most is How Well You Walk Through the Fire,
and as I was putting this piece together,
I was thinking about that.
But as we end this discussion, I think
what matters most is what makes you tingle.
And when you tingle, know that and say
what is this connection?
How is this happening?
When you're in the room with a patient, a family member,
and you get those tingles or those chills,
that's a big indicator.
And that's telling you something that I don't think
we teach in the classroom.
I don't think we can teach in the classroom.
And if we can figure out how, we should start doing that.
MARCIA DAY CHILDRESS: Well, and how
we could set up some of our educational settings,
so that tingling can happen.
I mean, we're not going to be able to do
this with lectures saying, OK, tingle now.
TIM CUNNINGHAM: Yeah, a tingle lecture.
MARCIA DAY CHILDRESS: So thank you
all for being here with us today,
and we hope we'll be sending you out with some new tools,
new recognitions.
Please join us next week.
We have the first of three programs addressing aspects
of the current opioid epidemic.
Next week we pair with medical grand rounds
for a program that continues on a conference that
begins next Tuesday.
We will have representatives from two first nations
of Canada, the Ahtahkakoop Community and the Big River
Community, plus Dr. Stuart Skinner
from the University of Saskatchewan
School of Medicine.
They'll be talking about first nations resilience,
two communities take on an epidemic.
This is also co-sponsored with global health.
And what we'll be looking at are these two indigenous
communities' grass roots response
to a devastating epidemic, not only of opioid use,
but also of HIV.
So please join us next Wednesday 12:00 right here.
Thank you.
[APPLAUSE]
And thank you Tim Cunningham.
TIM CUNNINGHAM: I have two chickens
if anybody wants a chicken.
They're-- these are like high quality Amazon [INAUDIBLE]..