The Q Word Podcast
“The Worst Thing I’ve Ever Seen”
Lisa: We have an interesting episode today that kind of organically came from a couple of conversations you’ve had just recently, right?
Nyssa: Yes. This is something that’s been rolling around in my head and fascinating me after a couple of conversations that I had. It is basically an extended public service announcement for our lay people…
Lisa: Like me?
Nyssa: Yes! Like you. And it comes with a caveat that this episode is not for our listeners who have a delicate constitution and it is not appropriate for the children of our listeners.
Lisa: We do put an explicit tag on our podcast- not because we drop too many “f” bombs but we do sometimes venture into territory that we don’t think kids will want to listen to. So folks, it’s a heads up for you if you have little kids in the car, you might want to put your earbuds in.
Nyssa: Listen to Radio Disney.
Lisa: Yeah… don’t put your earbuds in while driving. Why don’t you just listen to it while you’re vacuuming or something?
Nyssa: Yes. This started with a conversation I had while I was on a girls weekend with our other best friend Michelle. She had this conversation with me saying, “I worry about you… I worry about some of the things you see and how do you handle some of the things you’ve seen. What is the worst thing you’ve ever seen?”
Lisa: Yep. I remember that.
Nyssa: You know, it had me thinking and pondering some stuff and it was about two weeks later that my family and I are used car shopping. We are actually test driving this used car. My husband and my son are in the front seat and I’m in the backseat with the used car salesman. He’s making small chat and he asks us what we do for a living and when I told him he says “ Oh! I bet you see some stuff.” And I said, “Yeah… I see some stuff.” And he said, “Well what’s the worst thing you’ve ever seen?”
Lisa: Ok. So it’s a popular question.
Nyssa: Yeah, so I get the question within two weeks in two very different scenarios from two very different people. You know, when I started really mulling this over in my head.
Lisa: This isn’t just different people… These are people with vastly different relationships to you.
Nyssa: That’s right.
Lisa: Right? On one hand it was one of your closest friends and the other hand it’s a complete and total stranger. But they’re both asking you the same question.
Nyssa: That’s right. And I know how I answered those two questions and those two conversations… I wondered how other people respond when they encounter this question. What answers do they have. I wondered if they had a clever, pithy, pre-formed standard answer that they gave and I also wondered if it was the same brief, pithy answer that I give. So I asked them. I went to about 15 of my dear friends and colleagues who are emergency nurses and emergency medics and posed this question to them: “What do you do or how do you answer when someone asks you, ‘What’s the worst thing you’ve ever seen?’ and “Does your answer change based on who is asking that question?”
Lisa: Got it.
Nyssa: What I thought was really fascinating is as they answered me, there were a number of trends that emerged in their answers. So two things about that. One, I want to give a shout out to those friends of mine who were willing to answer this question for me. Not only because they are friends and fans of the podcast, but also because this is an intensely personal thing that we are talking about and they were willing to go there with me. So huge shout out to them and I am appreciative of their honesty with me. Two, this is not something that we are taught in nursing school. This is not something we are warned about in orientation. So the themes that have emerged are all things that we have fumbled our way through and figured out on our own.
Lisa: So you’ve been warned about HIPPA and keeping privacy and those sorts of things but not about the emotional reaction that you, as a nurse, may have to receiving this question? Is that what it is that you’re not taught?
Nyssa: Yeah, or that people will even ask you that question frequently. Or what would be a possible response for you to give. There are a million responses. So it’s interesting to me that many of us would come to the same conclusion just fumbling around in the blind on our own. What’s interesting is that I wasn’t asking them, “ What’s the worst thing you’ve ever seen?” I was asking them how they handle the question. But many of them shared with me anyway.
Lisa: That’s clearly a response mechanism that some people are giving you. They’re ready, almost immediately, to trod out whatever the answer to that question is without even thinking about it. They’re like “Well here’s this story that I’ve got. This is my one. Take it or leave it.”
Nyssa: Right. And I think that it matters that I’m a colleague and a coworker and that I’m coming to them with this important question. So the way that people deal with this is very interesting. One, and this will not surprise you, is that sometimes people will deflect with humor. Here are some of the responses that I got:
“Well, my direct deposit.” Or how about “the staffing grid on a Monday.”
Lisa: This almost falls under gallows humor.
Nyssa: Yes! That’s why you wouldn’t be surprised to hear it! Ok how about “The worst thing I’ve ever seen is an 89 year old naked.” Or “when the Falcons lost the Super Bowl.” My personal favorite comes from a nurse Ashley who says that the worst thing she’s ever seen is pineapple on a pizza.
Lisa: And if it’s in the ER it’s even worse!
Nyssa: Well what I think is funny about that one is another friend of mine, a critical care medic named Kelly said, “Why is it that you’re always asking me these hard questions? Why can’t you just ask me if pineapple belongs on a pizza?” So this was a theme that emerged, a very important question that needs to be answered in the emergency care world. I’ll weigh in and say I’ll eat anything. Pineapple on a pizza is fine with me.
Lisa: Yeah. I kinda like it. It has its place in the world.
Nyssa: I think we’re in the minority. So humor is one of the common ways that people deflect this question, and it’s in the hopes that the asker will recognize that I’m not going to answer this, so here’s a funny thing to throw you off of this scent.
Lisa: So I think the definition of the word “worst” means different things for different people. Would you file under the “humorous response” somebody who gives a story about the kind of thing that we did in our poop episode? Like a poop story or a puke story? Something where no one’s life is really on the line and no one is really hurt but there is something kind of disgusting or gross about it? Is that humor?
Nyssa: So that’s more of the second theme that emerged. What healthcare providers will do- emergency nurses, and I will say this question is posed to physicians and respiratory therapists and patient care techs and paramedics and I would venture to guess that it’s posed even to nurses that work outside of the ER. But I know this is very common in emergency nursing because of what the public assumes that we see. So what these emergency nurses and emergency care provider will do is that they try to dissect the mind of the person that’s asking so they want to say, “What is it that they really want to know? Do they want a hero story? Something that’s worthy of a TV drama? Do they want gore? Do they want something funny? Something salacious? Are they asking because they’re curious? Are they asking because they want to live vicariously? What’s going on in their head?” So for me, the used car salesman, I interpret as he probably wanted gore. So I’m going to give him a good amputation story about that one time when I held a woman's foot and ankle in my hand while she was laying over there on the stretcher. That’s what I imagine he wants. What we recognize is that these people don’t want to know the worst thing that we’ve ever seen. These casual people- the lady at pilates or the used car salesman- they don’t even know what the worst possible thing is out there. I think I’ve mentioned this to you before, when I had my first job as an emergency nurse, I remember one thing from the interview. I sat across the desk from Angel who had offered me the position. We had gone through all the questions and back and forth and then she offered me a piece of advice. She said, “ In this job you’re going to see the good, and you’re going to see the bad, and you’re going to see the ugly.” And I remember as almost a complete naive, undergraduate nurse, thinking, well I can imagine what the good is… and I can imagine what the bad is… but what is this ugly that she’s talking about? And so I also remember getting into the job and seeing the ugly and recognizing that this is what Angel was warning me about. This is it. Right here. In this room. When people are asking you what’s the worst thing you’ve ever seen, you’re thinking of the ugly, they’re thinking of the bad.
The third way that some healthcare providers will answer this question is by saying something like, “You know what? You don’t want to know.” And just shut it down with that. Or “I can’t talk about that.” When someone says, “I can’t talk about that”, you’re letting the asker assume that it’s for legal reasons or HIPPA reasons when it might just be, “I don’t want to talk about that. I can’t.”
Lisa: Yeah, it’s like making a Vietnam vet talk about what gave them PTSD. It’s kind of an insensitive question actually.
Nyssa: Other people say, “You wouldn’t believe me if I told you.” And then some people will blame HIPPA. You know, it’s not allowed, I can’t talk about this. Which is partially true… You’re not allowed to give too many details.
The final category of people are the ones that are going to shoot straight with you. You ask them this question and they look you in the eye and drop the smile and tell them exactly the worst thing that they’ve really ever seen. One of my nurse friends said, “I tell them this because I want them to know what we deal with day in and day out. The other version of that- when they get real with you- is they say, “So you want me to relive the worst day of my professional career and another human being’s worst day of their life for your entertainment purposes? No. I’m not going to do that.” That’s the way that they get very real with it. Really, you could ask the same emergency nurse this question on any given day and if I’ve had a really bad day and my patience is shot, you might get that last answer. Oh really? You want me to relive that right now? No, I’m not going to do that. Typically I say things like, “You wouldn’t believe me anyhow.” That’s my go to answer. But you really could get any of these answers on any given day by the same provider, just depending on what’s happening in their lives and in their career and the day that they have had.
Lisa: Have you encountered people that when they’ve been given that answer, the “Oh really? You want me to relive that experience?” that they say, “No really! Tell me. I want to know.” Are they persistent? Or are people normally respectful of your desire to not go there.
Nyssa: So I have never used that honesty one before, I think if I did, though, I would turn on my heel and disengage. I wouldn’t give them the opportunity. If I’m in a place where I’m not in the mood to talk about it because it has just happened to me, I would turn on my heel and be done.
The other theme that is really important that emerged is that these emergency nurses and medics say that it makes an important difference in terms of who is asking the question. So, when my best friend asks me, “I’m worried about you… What is the worst thing you’ve seen and how are you dealing with that?” Or my spouse asks me that. This is a very different answer and a very different consideration for me than when this random stranger who has been in my life for 5 minutes asks me.
Lisa: That’s because you know we are trying to gauge “where are you in the moment.” We care deeply about you as a human being. We aren’t just expecting you to perform for us on demand.
Nyssa: Right. That’s coming from a very different place than “I want to live vicariously through you” or “I want to hear something gory.” This is a whole different thing. There are emergency nurses who need to tell these stories. So they may even initiate the conversation and come to you. Sometimes we tell one another and we use that as a way to decompress or commiserate these terrible days that we’ve seen and had. I found a lot of nurses who have said, “ I will never tell my mother this. Even though she is very important in my life and close to me. I’m going to protect my mother. ANd I’m going to protect the public. They don’t want to know this ugly that we see. They think they do but they have no idea. I had another nurse tell me that they get this question sometimes from children at a career day. Certainly they’re not going to answer truthfully. They’ll give them some PG version of something dramatic and TV worthy that they’ve seen.
Because people ask this, many times, out of morbid curiosity because they don’t realize what this ugly is that we see and because they don’t realize what they are asking, whatever the answer is that we give, if we don’t have something prepared and clever to answer right away, we do go through this sort of rolodex in our head of bad cases that we’ve seen. So I’m just going to tell you. I’m going to tell you that there were themes that emerged when people told me the stories of the worst thing that they had ever seen. These are the things that we see.
The first thing is, the worst thing that we see, is dead babies. Dead children. Dead toddlers. When a child dies from illness or from an injury, it’s the bad. But when a child dies at the hand of a person who is supposed to love them and protect them the most in the world, it tips over to the ugly. That’s what we see. We see that sometimes. For me, those are the cases that I never forget. Those are not the stories that I’m going to tell you for your entertainment. It would dishonor those children. But I keep them very close. It is my way of honoring and remembering these little people who could not defend or speak for themselves. That then becomes my job.
The second worst thing that we see is when we tell a mother that her child has died. There is a scream. It is a certain pitch and a certain duration and a certain volume. And then hands go to the mouth as if to squelch the scream that has already escaped. And eyes clutch shut, as if to block out the information that you’ve just given them or the sight that they’re seeing before them if they’re at the bedside. And then they crumple. Their legs go out from under them and they deflate. Sometimes they crumple to the ground and sometimes they crumple on the stretcher and sometimes they crumple on you. You know, when we get into healthcare, we get into it to help people and to fix broken things. There is nothing that we can do in that moment that is going to unring that bell for her. As a nurse, standing there, it is the most helpless feeling.We can put our hand on her shoulder, or hug her, or scoop her up, or cry with her, or provide kleenex and water and a chair. We can do all those things, but nothing is going in this moment. But just to be there and share it with her. It’s one of the worst things that we see.
Lisa: So it’s as if the moment that the child passes away, your attention then becomes caring for the parent. The mother, and presumably the father to make sure that they have some comfort in that most crucial moment of their lives. Is that correct?
Nyssa: Yeah, so when we have a patient that dies- whether it’s a child or an adult- the family now becomes our patient.
The third worst thing that we see is bodies that come to us contracted, and cachexic, and ulcerated, and trached, and pegged, and they are shells of humans. There is no quality of life there. There is maybe very little cognition if any. But we are asked to do everything to keep this shell of a body alive. This is a really difficult ethical place to be in and this is one of the reasons why I take every opportunity to say that if anyone ever lets me live in that condition, I will come back and haunt you. Don’t let me do it.
Lisa: I’ll get that tattooed on me somewhere.
Nyssa: Yes. So those are some of the ugly. There’s a lot more. It’s often, bottomline, some of the things people do to one another that tips something over into the ugly.
Lisa: This sounds as if there’s a huge emotional component to what you’re seeing that elevates something from bad to ugly. Whether it’s someone else’s deep grief or some sense of what a wasted body is like or something that has to do with the deep suffering of your patient.
Nyssa: That’s right.
Lisa: So it’s an emotional response. That’s what makes it ugly.
Nyssa: That’s right. And oftentimes, not always, but things that are preventable. We can’t always keep children from getting cancer. We can’t always prevent a motor vehicle collision. Sometimes an accident is just an accident. But so many of these things that fall into the ugly category are 100% preventable. Never had to happen.
So don’t ask emergency nurses this question. Unless you are very, very close to them. Don’t ask. This is not a fun, party conversation. This is not a parlor trick.
Lisa: I think it’s a small talk thing. You meet somebody and ask, “Oh, what do you do?” It’s hard to say, “I’m an accountant” and then ask, “What’s the… coolest… math you’ve ever done?” But with a nurse, it seems to be the right thing to do. “Oh wow, that’s cool. I want to get to know you a little bit better. Talk to me a little bit about your job.” And inevitably the next thing is, “What’s the worst thing you saw?” or “What’s the worst thing you’ve ever seen?” I think it’s just small talk.
Nyssa: Yeah. And I don’t think people realize what they’re asking. I really don’t. And that’s why so many things happen in the emergency nurse’s mind when that question gets asked. First of all, those cases sometimes come to mind immediately. Or we are trying to dissect what it is that you really want to hear. What can I give you that will satisfy this small talk, social scenario. Or, this person needs to be taught a lesson not to ask this again. But there are a lot of things that you can ask me. Ask me about a miracle I’ve seen at work. Those happen all the time, too. You can ask me about the most amazing thing I’ve ever seen at work. You can ask me about the goriest case, or the funniest case. I can give you lots of items in orefaces that shouldn’t be there stories that I’m fine with recounting.
Lisa: So it’s interesting you just said the goriest thing because I think when people are asking the question, “What’s the worst thing you’ve ever seen?” they do mean the goriest, like what’s the bloodiest… so I think that would draw a fine line.
Nyssa: Yeah, I do too, and I will give a good amputation story or a good bone sticking outside the body story and I’m ok with that.
Lisa: You are?
Nyssa: I am. So going back to Michelle’s question when she asked me, “You know, I’m worried about you. I’m worried about the things that you see. How do you handle it? What’s the worst thing you’ve ever seen?” I asked her later, “What prompted you to ask that question?” It felt very much out of the blue. And when she asked me that, I immediately started scrambling, and thinking what have I said that has made her ask me this? I mean, I’m fine. I’m dealing fine. I haven’t had something particularly bad recently. I haven’t had something ugly that I’ve mentioned that she might be onto… Why is she asking me this? That was my thought process. I immediately kind of bristled and she noticed that and she said that I got sort of defensive and scrambly. I wondered what is she seeing as the chink in my armor? Because I’m fine. What she said was when I went back and asked her, “What prompted you? Because it felt very out of left field, you know, out of nowhere.” She said, “Well it was a couple of social media posts that you made.”
Lisa: Yeah, like when you go onto Facebook and make some sort of general comment about a type of patient- no one in specific, no HIPPA violations- just going on and kvetching.
Nyssa: And the social media posts (cause I went back and looked) were kind of snarky. They were snarky about patients- not the ugly, and not even the bad- but about patients who abused the system. People who are coming in with non-emergencies and treating me like a waitress. Or people who are making really poor decisions about their health and then expecting us all to pick up the pieces. She said, “Snark was unusual for you and I was wondering if it was wearing on you.” So it’s really interesting when you’re in a place where you have best friends who know you better than you know yourself because we don’t get burned out by the ugly, or even the bad. Maybe the ugly, yeah, but the bad. We go into this profession to care for emergency scenarios. We go into this for the critically ill people who need us on their worst day. What burns us out, and what wears us down in our compassion is those ones who show up with a non-emergency who should be at home in bed, drinking Gatorades, or who should have gone to their primary care provider, or who are just looking for attention and are then going to snippy with me and short with me and treat me poorly. Those are the ones that burn us out. Those are the ones that prompted my snarky comments that she asked me about. So it was interesting that she thought that it was some of the worst things that I had ever seen that might be doing this to me when it was actually the run of the mill abuse of the system that was making me feel that way.
Lisa: So I remember when we were talking about this that I, too, was worried about a level of frustration that I had been seeing growing in you. I guess, because you are such a compassionate person, I know I worry about you seeing so much that you become desensitized and then that level of compassion that has always been one of your characteristics would be somehow diluted by the fact that you’re seeing things that have now frustrated you. This is a job that you love, but when you start expressing frustration, we worry about you not loving it anymore and then we worry, “What else is this chipping away at inside of you?”
Nyssa: Full transparency: that happens. I’ve been doing this job and this specialty long enough to know that it goes in peaks and valleys. It’s a little bit like a roller coaster where I do feel that frustration and feel like I’m losing my compassion and feeling burnt out and then something has to happen to where I can regain that. For each practitioner, that’s different.There’s a lot of information out there about how you can do that, and that’s definitely something that we should address. But sometimes focusing on those things that we talked about, the miracles that you can see everyday at work if you’re looking, the good catches that you make, the amazing things. Those are the things that I cling to to help me regain that. Taking care of those patients who really do need me to be there for them.
Lisa: So I’m thinking that the question should be, “What’s your favorite story from the ER?”
Nyssa: Yeah! I would love to answer that question.
Lisa: And for some people it might be, “My favorite story is when I saw this really horrible amputation!” or “My favorite story is when I was able to save this life.” I think this allows the nurse to choose whatever type of story they want to tell without feeling pigeon-holed to have to say something that is either going to elicit an unsympathetic response… I would hate to tell someone, “This is the worst thing I’ve ever seen…” and then have that respondent, like the used car salesman, be like, “Really? That’s it? Well that doesn’t sound that bad.” I could see that leading to a negative response from your audience member that would somehow invalidate the fact that this was the worst thing that you had ever seen. So maybe your favorite story from the ER is the right way to go.
Nyssa: That would be a great one! So, bonus information for those of you that are friends with emergency nurses: when you see them post something on Facebook like, “Please, please, please make sure that your car seats are installed properly” or “Everyone go home and hug your babies extra tight tonight” or “Put down your freaking cell phone while you are driving”, they are giving you a little crack into the day that they have had- a little window. It’s likely not something that they can talk about that day. It’s likely not something that they can give you a lot of details with because of HIPPA but when they are reaching out they are both warning you about some of the dangerous things that are out there that have consequences that have consequences but they are also revealing to you that they might need you to check on them. Just, “Are you ok?” So those are some vague-booking things that emergency nurses do that kind of tip you off onto the day that they have had. When an emergency nurse says, “I went home from my shift tonight, stripped down naked, and bathed in bleach” you can bet that they triaged a whole family with scabies or bed bugs or something like that so… this is just some translations.
Lisa: This is a Public Service Announcement for we lay people. Definitely. But what coping mechanisms do you have when somebody like a casual acquaintance or a used car salesman asks you this question? I mean, whatever your response may be, whether you tell them the gross story or whether you choose not to or whether you choose to turn on your heel, you disengage… you’re still stuck with an emotional impact at that moment. What do you do to step away from that emotional impact that that question just engendered in you?
Nyssa: A lot of times it ends up at the kids. Sometimes my answer is, when people say, “What’s the worst thing you’ve ever seen?” I just say, “The kids.” or “The children.” and I just kind of leave it dot dot dot without any details. Often the follow up question is, “How do you do that? How do you manage that?” My answer is something along the lines of, “You know, kids are going to get sick and kids are going to get hurt and somebody has to take care of them. Why not someone like me? Why not me? Why not someone who can do it with love and compassion? Children are some of the most resilient people on the planet. So you kind of have two schools of thoughts with healthcare providers. Those who don’t want to take care of kids at all because it is way too tender and way too close to them, and then the other school of thought who say, “If anybody is going to survive something bad, it’s going to be a kid.” So they cling to that resiliency. That’s where I fall. The reason I’m a nurse is because of an incident with one of my children who bounced back with the most resiliency. That’s a story for another day, but I think that’s why I feel that way.
Lisa: I see.
Nyssa: So what I would like to know, or what I would like to say is if you’re a lay person and you’re listening, consider all of these things when you approach your emergency nursing friends.
Lisa: Yeah… This is not an appropriate ice breaker. If they’re a stranger, it’s not a good ice breaker. If you are not a stranger and they are a friend of yours, consider the perspective from which you are asking this question. Is it a place of care? Is it a place of concern for your friend? Or are you just looking for a romping good story that you are going to be able to go tell at a party? If it’s the latter, it’s probably not an appropriate question.
Nyssa: If it’s a dear loved one of yours and they scramble like I did and they’re not ready to answer that question in that moment, you have just opened up the door to say, “ I’m available when you’re ready.” In the Michelle-Lisa story of mine, I came back several weeks later and said, “Ok. I’m ready to talk. I’m ready to tell you. I need to tell you now.” But, the door was open to let me know y’all were willing to listen to me and y’all were interested to listen to me. And that was important. So for nurses who haven’t been doing this a long time and maybe haven’t bumped into that question many times, I hope that you’ve got some options here of things that you can say so that you’re not caught off guard when this question does come and that you don’t have to necessarily revisit all of those things that you’ve seen unless you want to. I would like to know what is your clever, pithy answer? What’s your response when you get this question? Do you have other thoughts or ideas? I’d love to hear those.
Lisa: You don’t have to tell us what it is that you’ve seen. You don’t have to answer the question, but we are curious how you answer the question when the question is asked to you.
Nyssa: If you do need a sounding board for someone who knows and someone who cares, and you’d like it to be a virtual stranger, we are here to listen for that as well.
Lisa: Absolutely. Folks, this is your public service announcement. We should grab that “The More You Know” rainbow, the little star that goes across the screen.
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