Critical care medicine is a passion. It checks all the boxes for me: quick thinking, quick action, and even quicker rushes of adrenaline. I became a pulmonary/critical care nurse practitioner in 2016. The field was exciting, and I was ready for the challenge. I read the current literature, attended pertinent conferences, and worked closely with board-certified intensivists. And I worked hard. I participated in every code blue, listened to every physician, nurse, or nurse practitioner conversation, and perfected my procedural skills. I performed these skills with notable technical precision and in record time. I did this with a bit of swag.

I saved lives on the brink of catastrophe. If a patient with an upper GI bleed cannot protect their airway, let’s proceed to intubation. A central line is needed in the patient with septic shock; let’s start the clock. Perform a successful resuscitation of the cardiac arrest in the radiology suite; I got this. I saved lives from the work I was doing. Critical care was intoxicating, and I was good at it. I floated around the intensive care unit (ICU) like a champion boxer. Carrying so much swag, I walked around the unit almost to the point of arrogance. Well, flirting with that line…I think.

But at 6 a.m. one morning, the confidence suddenly disappeared. I finish my shift and sober up from the adrenaline rush. I leave work, but all that swag and bravado would remain in the ICU. Once in my car, self-critical thoughts instantly fill my mind. Did I miss any life-threatening issues? Did I have tunnel vision on that GI bleed case? That patient in bed five with septic shock had no chance of surviving, right? Would they have survived if someone else was caring for them? How can I manage these patients? I am only a nurse practitioner. I never went to medical school or completed a fellowship. And now, I am being asked to care for critically ill patients independently. These thoughts flood my mind the entire drive home.

Once home and extremely tired, I climb into bed and fall asleep. But sleep was never restful. I wake up two times, three times, or more. Each time, I perseverate about all the decisions I made the night before. I am anxiety-ridden until I fall asleep again. This continuum of highs at work and lows at home repeats for 3 years.

Feelings Bubbling Up

My wife, daughter, and I drive to the local mall on a brisk fall day. We walk by the same storefronts we had passed so many times before. This time something is different. I am on high alert. Feelings of panic and doom come over me like a window shade slowly pulled down. I need to leave now. It feels as if someone was playing bongos on my heart. This must be a panic attack, I tell myself. I feel as if I will break down in front of my wife. My wife and daughter load up in the car. I sit behind the steering wheel, silent and panicking. I knew these feelings would eventually subside, but for now, I am consumed.

Sitting at the steering wheel, I want to apologize to my wife for not having the mental toughness to work a job that thousands of others perform. For not being the strong, silent type. For refusing to seek help despite suffering from feelings of panic, anxiety, and depression. These feelings of anxiety and depression began in high school with severe ebbs and flows that worsened during my college years. Now, this job with literal life and death consequences set it off again as if on high-dose steroids. I felt like a David Bowie lyric personified: I was “putting out the fire with gasoline.”

We pull up to a red light, and I desperately want it to turn green. My wife looks at me as I stare forward and tightly grasp the steering wheel. She says, “What is wrong?” I don’t know what I am supposed to say. I tell her, “I think I am having a panic attack.” I am holding back the tears welling up for a reason I still cannot quite understand. The light turns green, and as if in an instant, we are sitting in the living room. My wife is in the recliner, and I am on the floor, deflated and exhausted. I begin to unpack all of my feelings.

Sitting on my living room floor, I speak through jumbled conversation that vacillates between “I am competent” and “I’m an imposter.” I tell my wife about these feelings of unrelenting anxiety and guilt. I feel defeated, a fraud, someone others would describe as objectively good at their job but not knowing if that is enough. In the ICU, not every patient will survive despite our best efforts. But if my patient had a poor outcome, I felt I was responsible. If only I had worked harder or acted sooner.

Back to Reality

I continued this job for another year. The feelings of anxiety, guilt, and depression did not diminish. Every morning I would park my car in the hospital parking lot, and a knot in my stomach would form. I would try and “will” it away. That never worked.

As a last effort, I reached out to colleagues. Responses like, “What you are experiencing does not go away, so you learn to deal with it and move on,” were common. Was that it? How can they just “move on” while I am having an existential crisis?

This crossroads in my life was not easy to accept. But at this point, I had two options. The first option was to “stick it out” and continue in the ICU. Not the most appealing choice, but the easiest if not the laziest option. The second option was to quit my job, move to a position with less stress, and maybe seek mental health treatment. Still not appealing.

After much introspection and many discussions with my wife, I resigned from the full-time ICU position, became a vascular surgery nurse practitioner, and finally sought mental health treatment. I am proud to say that for the past 2 years, I have been in therapy and taking a selective serotonin reuptake inhibitor (SSRI), more commonly known as an anti-depressant.

Something Completely Different

My world has changed. The panic attacks I experienced in the past slowed to almost a complete stop. Situations that would certainly inflict severe anxiety now did not. My mood did not fluctuate to such extreme ends. Mental illness is not often curable, but it can be managed. It is a work in progress that will continue for the rest of my life. I finally accepted this reality, and I am okay with that. Often I look back and wonder what my experience in the ICU would have been if I had sought treatment sooner. Undiagnosed anxiety and depression severely affected my work in the ICU, and the work in the ICU severely affected my undiagnosed anxiety and depression. Undergoing therapy and medication treatment would have helped me through those years. If only I was not so stubborn and sought help earlier. However, dwelling on the past is not helpful. I’ll take what I learned and move forward.

So, now what? First, working in healthcare can be extremely rewarding and professionally satisfying. I don’t believe nursing is simply an occupation. It is a vocation. A vocation that runs the gamut of bringing life into the world and being present when life has ended with much in between. Not all people can say they have the privilege to share in a stranger’s life and death.

I wish I had a guide through my challenging times. I felt so alone for a very long time. Combining that with undiagnosed and untreated anxiety and depression does not make for a healthy and productive life. A takeaway point from my cautionary tale is to be aware of your feelings and how they affect your life. Make them a priority. This brings me to the second point. Speak up about these feelings. It is hard to make sense of this on your own. With anxiety and depression, this is virtually impossible.

And Now This

I am lucky to have a robust support system. My wife has been my north star through all of this. My parents and brother have always been faithful supporters. I do not know what I would have done without them. And when you are ready, seek professional help. It may seem easier to try and “fix” this on your own, but seldom is that achievable. Do not be afraid of therapy and, if needed, medication. Despite my vulnerability as I write, I am proud I decided to improve my being and choose wellness.

My anxiety and depression felt like weaknesses instead of diseases. These feelings can be suffocating. But the tide is turning. We are beginning to normalize self-care and wellness instead of normalizing anxiety and depression as unavoidable occupational hazards. I believe that during my career we will see a significant increase in mental health resources for healthcare professionals dealing with anxiety and depression — no more “stiff upper lip” culture. There is much work to be done, but I believe we will one day work in a system that provides quality care to both patients and healthcare professionals. Finally, we will be putting out the fire with an extinguisher.

Steven Bocchese, MSN, APN, CCRN, is a nurse practitioner in Pennsylvania. Steven is also pursuing a PhD in nursing focused on moral distress and burnout in ICU nurse practitioners.

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