Dr. James Maskalyk: Making the Emergency Department Healthier for Everybody
(Access show transcript) Being an emergency physician and cancer survivor has taught Dr. James Maskalyk the importance of stress management and pursuing a greater well-being. He’s now dedicated to making a difference within medical culture through the role of Wellness Director across several Toronto hospitals.
Burnout is a prominent issue for healthcare workers and a topic Dr. James Maskalyk is passionate about. This led to the creation of a wellness program at St. Michael’s Hospital and later across 15 hospitals in the GTA through the University of Toronto. The program promotes facets such as peer support for providers, critical incident debriefing, and more.
On the episode, Dr. Maskalyk also touches on small yet important steps that can be taken to boost overall mood in the emergency department, such as mindfulness practices, and snacks.
Mentioned in this Episode
- St. Michael’s Hospital, Unity Health
- University of Toronto
- Dr. Sara Gray
- Dr James Orbinski
- Médecins Sans Frontières (MSF)
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Michelle Holden: Hey listeners, Michelle here from HIROC. Back in 2018, HIROC staff book club read a book called Life on the Ground Floor, written by a Toronto physician, Dr. James Maskalyk. Skip to a few years later when stories about Dr. Maskalyk in Toronto Life in the Globe came across my desk. It felt serendipitous and we knew we had to get him on the show. For Dr. Maskalyk, a lot has changed since life on the ground floor. He's now the wellness director at St. Michael's Hospital and is growing a wellness program at 15 other hospitals. On the episode we talked to Dr. Maskalyk about why his work on burnout, stress, and self-care matters for ED teams now more than ever, so let's jump right in. Hi, and welcome to Healthcare Change Makers, Dr. Maskalyk.
Dr. Maskalyk: Glad to be here.
Michelle Holden: Can you tell us just to start a little bit about who you are, what you do, and where you work?
Dr. Maskalyk: Yeah, that's a big question. I always start with the most difficult ones who I am. Well, I guess that's a shifting target. I would say there are kind of many ways I would describe myself in different circumstances, but I think most often my identity is grounded in what I do. I am an emergency doctor and trauma team leader at St. Michael's Hospital. In that role a physician has expanded as I've learned that medicine is not something that just happens in the emergency room, but something that very much follows us home as practitioners and patients. I also have a role cultivating wellbeing in my colleagues at the University of Toronto and its academic hospitals downtown.
Michelle Holden: And so this role, I know that we've heard it as wellness director, you work with nine hospitals, is that correct? Affiliated with the university.
Dr. Maskalyk: It is growing. The mandate seems to ever be increasing. Last I checked it was 15.
Michelle Holden: Wow, okay.
Dr. Maskalyk: That sounds ambitious. And it is, I suppose because really your ability to contribute to another person's wellbeing is limited in a certain sense. You can create the conditions for such flourishing to occur, but it really is something that is at the behest of that person's individual choices of how they do medicine and how they live their life outside of the clinical act. But in terms of the offering, we're hoping to expand it even beyond those 15 hospitals to really every hospital within the GTA. And it really is just about beginning the conversation that doctors are people too and nurses are people too. And the people who are there who support us as porters, the people who cook the food, we are human beings working in an increasingly inhumane system to be honest. So I think this conversation about how to bring more of ourselves to work in a certain way and be vulnerable is just kind of a step that I didn't get in medical school. The way I look at it is just like a curriculum. What's the ongoing curriculum of deepening in your humanity?
Michelle Holden: And how did the role come about? So was it something you pitched, something that came to you?
Dr. Maskalyk: With Sara Gray, a colleague of mine, we were the first kind of wellness leads at our hospital that started five years or so ago. And we just were incited by this conversation, and we wanted to continue to make... We knew the ER was special meaning that we got to really live our values. We got to be part of a place that said yes to strangers no matter where they were. And I think both of us, I can't speak for Sara particularly, but I know for myself it was an avocation of a deeply felt hope for humanity, that there would be places that could offer help to someone no matter who they were or what health insurance they had or whether they're new Canadians or even had a health card. So we knew it was a special place, and we wanted it to be reflected in as many facets as possible.
So we wanted it to be kinder to us. So we pitched it. We got a small amount of money, but most importantly, we got permission from our emergency department leadership to make it a priority. So initially it was something we pitched, so it was quite successful. I can tell you more about that program should you be interested, but eventually it led to the recognition that it worked well enough with our group of doctors that I thought it would be worthwhile expanding. And it was in kind of organic ways, but we work at a university. We like to make things not just a practice. We like to make them systematic in a certain way and subject to inquiry.
So the wellness director position came about as a way to try to spread this throughout the network of hospitals in ways that were meaningful at the individual level. So I pitched that idea when they went through a series of interviews. Many people I believe interviewed, and I was lucky enough to get that position. So it's just early days, but now we're starting to slowly make sure that all the clinical sites at least identify in wellness lead, and then we'll discuss about what that would look like, what that program ideally would entail and, again, just start this conversation because emergency medicine in particular is in dire straits.
Michelle Holden: Yeah, it's busy and it's stressful, and I can't even begin to imagine some of the things that you go through. Do you have some examples of upcoming changes or projects that you're excited about as part of this role?
Dr. Maskalyk: I'm just going to mention before we move on to... I read the other day that the year before last in the US 200 emergency medicine spots, training spots around the country, went unfilled, and this year it's 500.
Michelle Holden: Okay.
Dr. Maskalyk: So this conversation's really relevant. Who is going to work in the emergency department for the reasons that you describe? You're not just the interface of something like COVID, which we stood there when we thought it was going to kill us, really, watching what was happening in Italy in particular. And then you're at the interface of a variety of different epidemics; fentanyl epidemic, the epidemic of anxiety that is sweeping through all people. And so it's really relevant for us to support our frontline workers. It went from banging pots and pans at the beginning part of COVID-19 to I saw people physically assaulted on the street because they were wearing scrubs. And there was such a surf of misinformation that it became almost dangerous to identify with working in the emergency department physically in terms of your social standing and certain circumstances too. So I bring that up just because I want to answer your question more fully about what examples of things that we're hoping to do to change that narrative a little bit.
Now firstly, I don't know what to do if people don't love the clinical act. If you don't love getting a stranger a glass of water, if you don't love seeing a young kid who's sprained their ankle and telling them it's going to be okay and giving them some Tylenol and some crutches, you must love that. If you do, then the emergency department is for you. But it doesn't mean that there aren't things we can do to make it better. So what that looks like for me is two kind of broad categories. One is taking the things you love, hopefully it's a clinical act, hopefully it's just being part of a team, identifying with this kind of greater values that I mentioned of being a place that any person can come, whether they're the president of the Royal Bank of Canada or a person who lives on the street and treating them equally.
That's dignity. That's dignifying humanity in my view. So if you love that, we want to make that more available meaning more accessible. So that would mean minimizing distractions. That would mean trying to make the system a bit more humane. What we want to do is build up the things we love the most, which is patient facing clinical activity, community, giving us opportunities to gather in groups of people who work in the ER. So we get to make friends there. Face it, the ER happens Christmas Day too, so we're just going to be spending Christmas there sometimes. So we want to develop this sense of community that includes having a space that is unique.
And what that looks like at St. Mike's is we have a doctor's, I guess you can call it an office/lounge that is bright and full of art and quiet and has snacks and a place where you can go and have a break or mourn a patient or talk to your mom or whatever you need to do. That doesn't happen at every hospital. Some hospitals, you go to work in the ER, and they're like, "Here's the broom closet where you put your coat," and then go. And it doesn't offer a lot of that softness. So we try to make place making something special for the people who work in the ER. So that's just an example of trying to make things that work for us that help us be more of who we are and more humane to ourselves.
And then there's a second category, which is the hardest parts about the job. Now that is unavoidable unfortunately. You're going to see catastrophe. You're going to see physical, sexual abuse, emotional abuse. You will be shaken by some of your position as witness. So we want to soften those somehow. Like I mentioned, the first part, that is a way to do it. We heal in community. It's hard to heal alone. That's why loneliness is such an epidemic. So the first part is trying to make this a better place, and the second part is trying to make it less hard. So critical incident debriefing, that's something that happens say in military and police, although I'd prefer a different paradigm because we don't really want to identify with those institutions. Not that I have anything against them, but we want to be kind of like a wide net for all people.
So critical incident debriefing is taking some of the hard parts of it, the witnessing being part of say a difficult trauma, losing someone who's young or having a distraught family and then unpacking that emotionally in a systematic way by offering debriefings, some right after the incident and then one a couple weeks later. I just did one last week about a bad trauma case. And then there is peer support. So having someone like a wellness lead could be an example of peer support, but diffusing that so there can be a person to call if you're having a tough time integrating a difficult experience or just having a tough timing in your life, peer support. Then there is kind of mindfulness. That mindfulness is something that rings out particularly strong in the literature on wellbeing in the emergency department.
And those things in particular are kind of facets of this program that I'm hoping to bring. I guess one that just escaped me that I feel strongly about as well is improving communication. So there's a couple different ways to do that that they're not competing but say complimentary. But the one that springs to mind is something called non-violent communication. Non-violent communication means speaking clearly about what's happening inside of you. So our patients who come in with a broken leg don't want to hear about my emotional turmoil because they just want me to fix their leg and give them the medicine and straighten it or whatever needs to happen. And that's how it's supposed to be and that's how it will continue to be. However, there is an opportunity for us to speak with each other about what's happening inside of us that could be more clear because vulnerability is not a skill that we learn in medical school or I never did.
We learned stoicism. We learned that you just answer that pager right away at three o'clock in the morning no matter what, and you just compartmentalize. So I don't think that's very healthy. And I think that what we're talking about on this podcast and I hope is the direction we're going is we just want to make the ER more healthy for everybody. So communicating is important. I'm rambling on, but I know we'll get to some more questions. But in this debrief that we did a couple weeks ago, I was talking to a colleague of mine, and I asked them like, "How did you feel when you heard about this resuscitation coming in?" And they said, "Well, I called blood bank and all that stuff." I'm like, "Well, that's not a feeling exactly." So I think there's room for us to just be a bit more honest about what's happening. And with that gets some kind of clarity about what we love about the work because we do love it and we just want to keep on doing it.
Michelle Holden: And maybe part of it in that last example is about practice in doing it and asking those questions again and again, kind of explaining that.
Dr. Maskalyk: Exactly.
Michelle Holden: No, I think all of those examples that you gave are much needed. And they sound not small, but simple and easy to understand, but they're big, big massive mountains. I know it's probably not easy, but to think about having a space that the physicians or the nurses or anyone in the ED can go to... We outside of that world think maybe that already exists, but you're right, it's probably something that we really need to build and integrate. And so I'm glad that we have you working there, but what are you hearing at St. Mike's about some of the progress that you're making, some of the changes?
Dr. Maskalyk: So I would say morale is improving and at my place is actually pretty good. I would say that we like the work, we like each other. We argue pretty amicably, but it's hard. I think there's a lot of room to grow. I don't really have the insight into what's happening at the other institutions.
Michelle Holden: You said it's early days, right?
Dr. Maskalyk: It's early days. And I think that this is the type of program that really needs to be administered at the individual emergency department and hospital level. That's what I'm hoping to do because you're going to need someone who is going to be able to identify local contributors to burnout and local ways to solve them. Because the top down approach, the very high level approach of trying to handle things from far away is kind of how the system got to be so crummy. People making decisions that affect my ability to work in the emergency department because they're trying to balance a budget or something like that, but they don't understand that there are very human consequences to some of those decisions. So what we're trying to do is embed people within each emergency department with the vocabulary of what wellbeing looks like for most people and apply that to emergency department workers.
Michelle Holden: I know you mentioned some of the literature as well as your experience obviously probably brings a lot of this, but where do you get ideas? Where have these kind of new projects come from? Are you talking to other physicians across the system?
Dr. Maskalyk: Yeah, I would just say like all good movements the inspiration is suffering, deep suffering, and then moments of clarity and listening to what people love about their work. I think for me, that's the most important piece is what people love about the work because just like inflation, once you start talking about it, it's there. Just like burnout's the same. If you even look at the burnout inventory tools, a lot of them are like, have you felt over the past couple of weeks despondent? It's queuing you to say yes, right? Of course, who hasn't? I mean, it doesn't matter if you're an ER worker or Starbucks barista or a radio DJ. Sure, there are times where you're wondering what the point is. So we're kind of still with that being the case ER workers chart the highest on burnout. So the ideas really come from what personally I've noticed through my work with say, frontline work with Doctors Without Borders in different environments, with the ER, what we love about the work, and then just listening really and just realizing that we're just human beings too.
And what are human beings like? I guess what the most popular thing is in my ER that has contributed to the kind of just the collective mood, probably snacks. That's kind of funny. But just everyone loves when the snacks come in and you feel like... And it's not because you can't afford snacks. Of course, you can. You can bring your own snacks, and they're just as great, but it's just the idea that someone out there cares for you at an individual level enough to do that. Sabbatical program, meaning we allow every person in the ER the opportunity. It's an opt-in scenario to take a month off a year in addition to regular vacations. That's a bit of an income hit if you're not working for that month, but you can make it up by working more shifts at the other times.
Everyone loves it. Who does it? Some people say, well, I have a renovation in the house or I'm a single income earner, I'm not taking that month off. That's cool. But it's not surprising. We're just human beings. We like time off. We like snacks. A lot of these things aren't really like cutting edge science, even though I think that if you looked there is a growing literature, a rapidly growing literature, on wellness and wellbeing. So the ideas kind of come from just from other places, but also just really from our groups and our intuition.
Michelle Holden: Because we in the offices also love snacks and time off, so I totally understand. And just listening to you, I have a young child, so I spent a little bit of time in the ED this year with him and just thinking about the physicians that we dealt with, not your ED, but they were busy and they were stressed and I knew it because of my work, what exactly was going on, but also they were human to us and talked to us after their shift, and there was just a real connection there. I want to just thank you and all of everyone who's listening because there was so much going on, the nurses, everyone. We knew that it was a tough time, but as you're talking about this job and how incredibly difficult as I'm thinking of that person and the care they gave us, despite all of that, so appreciate that.
Dr. Maskalyk: It's an honor.
Michelle Holden: So we have a number of physician listeners for sure, but especially at Rock, our audience is wider. You've mentioned kind of the nurses in the ED, some other professionals, but can you share a couple of burnout, stress management tools other than snacks, because those are key too, that anyone in the healthcare space can kind of leverage.
Dr. Maskalyk: I remember one time James Orbinski who is a friend of mine, and he was the president of MSF at one point, and I was pretty new MSF. He'd already done his presidency. I would come back from my second mission at that time, I guess, and we were both speaking at the same medical school event, and he hadn't seen me in a while. And so he said, "How's it going?" I'm like, "Well, man, it's intense." I'm just back from this refugee camp, and I had all these hopes for Sudan. South Sudan just became a country. I thought that would be a harbinger of peace, but they're fighting more viciously than ever. That town where I was working got evacuated and destroyed and this and that. I went on of this litany of catastrophes and he kind of stopped me and turned me to face him fully. And he said, "You know it's not your fault. It's not your fault some of the catastrophes that you see." And what I mean by that is when I talk to residents and I'm teaching them emergency medicine, sometimes I'll give them cases where no matter what they do, the person dies. No matter what they do. They do all the resuscitation right. They activate the right consultants.
They mobilize the tools in their ER. And the person dies because that happens. People get sick, people pass away no matter what you do, and you can feel like it's your fault, but it's not. You are dignifying them by being there and working in their best interest because that's what their family would want you to do. And it is a beautiful act. You standing there beside these people doing the best you can is one of the most beautiful acts ever completed by a human being. I mentioned that because it can kind of invert what seems like a responsibility to beat back sickness and death, but that's not really what you're there for. You're there to kind of soften the experience a person would go through if they were alone, but they're not alone because they have you, so just that perspective can sometimes help me.
And then in terms of actual strategies, well, I'll mention two. One is the pause, which is after you are present for say cardiac arrest or someone dies in the emergency department, something I like to say is we're going to do a pause. Anyone who wants to leave the room can, but the rest of us are going to take about 10 or 15 seconds to be here together. And sometimes people leave, most of the time people stay. And I say something like, I recognize that this person had a life and a family and dreams, and I recognize all the people in this room who tried to help them even though they knew none of those things.
And you just stop around this person who's passed away and takes 10-15 seconds, just quiet and feels like a long time. That's not very long. It feels like a long time. And into that space rushes a certain type of reverence almost for life in general and for the activity of what you're doing. All these people came together to help this stranger. And so then it becomes precious. The first of the question of what life is? What was that life that disappeared, and what is this thing that's coming together that's trying to help it no matter what? That's precious. So that's a strategy that... Because normally people just disappear and go on their phones or go cry or something and have their own private experience, but this becomes something shared, and the activity of what we're doing is shared, so why wouldn't the integration of it?
So there's that. And then the final thing I would mention is just personally I like periods of mindfulness, periods of mindfulness when I teach them to my patients, and I do that probably most days at work would be something that probably breath focus would be a good entry way. And an easy one to remember is called the 478. I guess, I don't know how you remember that, but 478. So 478 breath. So it would be inhale through your nose for a count of four. So inhale through nose for four, hold for seven; three, four, five, six, seven. Exhale through pursed lips like you're whistling, but you don't make a sound for eight; four, five, six, seven, eight. Do 10 reps of that. And what that does is kind of grounds you a bit, takes you away from the busyness and your thoughts in your head, stops and gives you a sense of presence.
And if you want to get physiologic about it, the slow exhale through purse lips kind of causes a gentle Valsalva maneuver, which activates the vagus scenario, which kind of slows your heart rate down, is kind of antidote to the hyperstimulation of the ER and our modern life of alerts and deadlines and just helps us remember who we are a little bit. So I recommend to my patients a lot of the time, 10 times when you wake up in the morning, 10 times at lunch, 10 times before you go to sleep, and it just kind of starts to balance. If I could recommend, I would say do it for a whole week at a silent retreat, but doing it for a couple minutes a few times a day is helpful too.
Michelle Holden: Those are great tips and something everyone should be doing, definitely myself. I know we do a bit of mindfulness with our staff here at HIROC and some of those kind of box breathing and those techniques are taught. So it's something again that takes practice. I think I just want to shift a little bit in recent interviews with the Globe and Toronto Life, you shared a bit about your experience with stage four cancer diagnosis during the height of COVID, I imagine an ultra stressful time. Just wondering if you can give our listeners who may not have heard that yet some background on this time and how it's shaped your life today.
Dr. Maskalyk: I'm a snowboarder and a mountain biker, and there's kind of rules that the two sports share is don't look at what you don't want to hit, look where you want to go. So if you're in a bunch of trees, don't look at the tree, look at the open spaces. So in that way, even though it kind of dominated my life since my diagnosis and my psyche, it actually forms less and less with time. But it was a very surprising turn of events because I thought I was one of the healthiest guys I know. I was working on my third book, and I went down to the US and this crazy 20,000 US dollar physical exam. The company who puts it on supported some of the expense, but that's the book cost anyway.
They MRI'd my whole body, did my genome and everything, and they're like, you're cool. So I'm like, wow, I'm immortal. And then a few months later I felt a lymph node in my neck and it turns out I'm just like everybody. I'm mortal after all. So through surgery and fear and existential reckonings and all that stuff, I find myself still here. I guess the difference would be I always knew based on my position that life was ephemeral, but now I know it. I know it.
And because I've been through those bitter times, they're not over by the way. I mean obviously you can tell that it still very much will remain an open question the rest of my life. The last news I have of it is in the ways that surgeons want to do... In their gentle advice, I mean, the last surgeon I talked to said I'm probably going to die of something else. So I don't know whether that's comforting or not, but certainly that's the case. But that said, who knows? Life ultimately is the temporary situation. So then the question becomes, what do you do with what you've been given? And I guess you hear this, it sounds trite, but the answer is just be kind to yourself and to other people and try to help others the best you can without hurting yourself.
And that just kind of honors the quick of whatever it is we are given when we enter this world that precious but slightly flimsy bit of aliveness that sits inside of all of us. And I think once you get a sense of its finitude, you realize the preciousness of it, and it's like someone turns up the color knob a little bit on the world around you, and you become more reverent, kind of more of who you are at a deeper level. If I could summarize what has been my experience and what my advice would be to most people, it would be get close to God and stay there.
Michelle Holden: Thank you for sharing that. I know as you said, you want to look toward the open space and not in the trees, but I appreciate that, and I think that it would kind of send a message and bring a lot of hope as you said and kindness to others. So thank you very much for sharing it. We're going to move into the lightning round. I know you haven't seen these questions yet, but hopefully you'll be able to answer them, and I'm sure you will be able to. It's supposed to be the fun portion of our show if you weren't already having fun. So the first question is, what are you watching or reading right now?
Dr. Maskalyk: I finished a show called The Boys. It's kind of trashy, but it's about superheroes gone wrong. And so it's kind of a trope on superheroes just being as craven and misguided as the people they're purporting to help. It is hyperviolent though, which I don't have a great... It's not easy for me to see, so I don't know if I can recommend it for most people. It's graphic and violent. So I'm glad to be kind of done with it. I started the show last night called Altered Carbon, which is about a future. All futures are dystopic. It's about a future where we carry our consciousness around in kind of a hard drive regardless of we can move it into different bodies. So kind of cool. I like sciencey stuff, so it seems pretty sound. And then in terms of reading, I was reading Gabor Mate's book called The Myth of Normal. Fiction, I'm always into both Kavalier & Clay, which is a book about comics, which I've enjoyed quite a lot.
Michelle Holden: Yeah, I guess it helps kind of de-stress in that element, that last one.
Dr. Maskalyk: Imagination. I just get to be play around, let my imagination be pulled to different places.
Michelle Holden: For sure. So next question. Who or what has had the biggest influence on the person you've become today? I know you mentioned a lot of your experiences, but if there was something else that came to mind or one of those.
Dr. Maskalyk: My mother. I think the people I admire the most who have influenced me the most, the common thing they have is they've suffered greatly, and her life and the way she lived it and the way she left it was just full of grace. And there's something about her and people like her. I know that I venerate her because she's my mother, but I've met people like her who you never know what they're going to say because they never say the same thing twice exactly. Even if you ask them the same question, they think about it and the answer comes from a place that even I don't think they know where it's coming from. So in terms of curiosity and love of God and nature and all that stuff, it comes a lot from her.
Michelle Holden: As someone who travels and has traveled a lot as we've heard, you find yourself stranded on an island. You're good in a crisis, so what three items would you have with you?
Dr. Maskalyk: My answer to that question is always yacht, can of gasoline and protein bar or something. But truly what I would want to have with me... Well, I think a blank book and a pen would be two things, I suppose, and a vessel for water. I think that's about it. Very literal, but also I've got a chance to record my last words at least if I have any insights as I face the end.
Michelle Holden: I think your first part about the yacht and the compass and the gasoline is good if you have hope that you're getting off the island. If you don't know that you're getting off, I'd like the book as well and some of those things.
Dr. Maskalyk: Yeah, you can light it on fire.
Michelle Holden: Yeah, exactly. So when you've had a hard day at work, which we know happens, what boosts your mood?
Dr. Maskalyk: I like outtakes, The Office outtakes, both the UK version. I just like watching people laugh, funny people. I can imagine that's the actual best job in the world, trying to make your friends laugh on camera. So if I want to a quick endorphin fix, I'll do Office outtakes or Will Farrell outtakes. Pretty funny.
Michelle Holden: Are you like most of us and rewatch the office several times during COVID?
Dr. Maskalyk: Yeah, yeah, yeah.
Michelle Holden: Okay, good. Last one, what's your favorite meal?
Dr. Maskalyk: One I've made recently was shrimp fried rice, so I like that. Make enough rice. I always make enough rice for two meals, put a half in the fridge, and then just heat that up with some even frozen vegetables, some soy sauce, and then cook some shrimp, throw it in there, and it's one pan. It's easy and it's delicious.
Michelle Holden: Our listeners should know that it's almost lunchtime here where we're recording. I did lie though. I'm going to ask one more question. What's your favorite snack?
Dr. Maskalyk: Mixed nuts.
Michelle Holden: Yeah, that is, okay. That's a healthy meal.
Dr. Maskalyk: Yeah. I mean, potato chips really. Probably if I was on death row and had a last meal, I'd be like, just give me a chip buffet because I think at the end of it, you'd feel so bad, you'd be like, okay, just kill me.
Michelle Holden: Just give me those chips.
Dr. Maskalyk: Yeah, yeah, yeah. Okay.
Michelle Holden: Well, with that, I am going to let you get back to your day and say thank you so much for joining us. This was really, really a great interview. I think everything that you shared will resonate with our listeners. It did with me. I know I walk away feeling different than when we started, so I just wanted to thank you for coming and joining with us.
Dr. Maskalyk: Well, it's an honor to be here and to have the trust of my patients and my colleagues who are in the ER this very moment helping other people.
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