Eddie are you ok, are you ok Eddie?

Chris Poynter on 30-12-2013

As I drive home from an unsuccessful paediatric resuscitation, Michael Jackson’s “Smooth Criminal” blasts out on the radio and I contemplate the above phrase. We see some pretty horrible things in this job and having a way of processing that trauma is vital. As a father of 3, I find paediatric deaths are the most difficult and they are the cases that stick strongest in the memory.

This case reminds me of one earlier in my training which highlighted the high emotional stakes of the job and perhaps also the lack of support for trainees in learning how to deal with these demands.

At that time a toddler had died in the ED after being run over on a driveway. The team present worked hard but the outcome was determined before arrival and when we stopped and death was declared, the wave of raw emotion in the room was overwhelming. Mum screamed with anguish as she grieved over her loss. Many of us wept but there was no pause. It was mid shift and the resuscitation team had assembled like a flash mob for the trauma call and dissipated just as fast. There was work to be done. I remember leaving in a daze, wandering back up to ICU, locking myself in the registrar room for a few minutes as I sobbed and called my wife for some support.

What struck me was the lack of a cohesive approach in supporting the staff involved.

We all gather memories of particular extreme situations during the course of a career and they are often powerful positive learning experiences in the long run. On reflection, some of the best of humanity is seen and often an uncommon dignity presents in those suffering the most and it is a privilege to be able to witness and be part of that regularly. It is with pride and awe that I look back on many of these memories and they certainly provide me with a grounded perspective of life and its difficulties. When I get wound up by my “first world problems”, I can often put them in their place as a result of what my intensive care experiences have taught me.

However, if medicine has taught me one thing it is that with every benefit comes risks.

Short term management is difficult. There are a number of ways of processing emotional trauma and every person will find what works for them over time. To a degree, much of the resilience we develop comes through exposure and experience.

I’m not a big fan of formal debriefs. They can easily be sidelined by a few while neglecting the quieter sufferers. However, I do feel that there is a strong role for mentors and collegial support. I have never worked in an environment of compulsory supervision but a friend in the police force who is also exposed to regular emotional trauma seems to think that it is useful - is there a role for this in Intensive Care?

Peter Hicks, a colleague with more years of wisdom behind him than me, took me aside after one such incident when I was in my SR year to share his approach and it has stuck strongly with me.

His main points were:

only those present really understand and so chatting with them can be cathartic as a debriefing mechanism.
expect to be grumpy and tired after a traumatic incident. This may not occur until a couple of days later and is normal.
We are all human and it is ok to grieve a little. Once the professional dust has settled, attending to your emotional needs is important
often the most junior staff may have massive trauma that they are struggling to process. If you don’t ask, you won’t know and often the opportunity to talk the situation through and have their questions answered can make a massive difference

This most recent incident will be another memory which will stay with me. It is now much more familiar and easier to manage. However, the day I am not affected by such trauma is the day I will worry that this job has burnt me out. Medicine is after all a humanity.

My only advice is to watch out for one another - often a simple phone call or text message can work wonders.

I’m interested in what others do and in any successful strategies which have been employed. I often bawl my eyes out several months later at home watching sad movies and, as well as the fantastic home and work support which I am lucky enough to receive, that seems to get me through.

Have a happy New Year everyone and take care on the roads.

6 Comments

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Hannah from Australia wrote 12-31-2013 07:53:13 pm
Oh dear, Chris, that sounds awful. Its also hard to read, as it brings back many unpleasant memories. We do carry a heavy weight sometimes. It would be nice if we cared for each other a little more.

Todd Fraser from Australia wrote 01-09-2014 11:18:27 am
Hi Chris

Your story is very familiar, I suspect to most of us.

I recall one very traumatic incident, resuscitating the drowned friend of one of my children, and having to tell his parents, who I knew fairly well. I was the only intensivist in town and it was a weekend, so there was almost no support. It was one of the most lonely and sad places I've ever been.

I suspect this story resonates with most, and highlights to me the important of developing close relationships with senior people, particularly when you're starting out as a consultant in ICU.

Your post raises the issue of psychological support for consultants - as a craft group we're intelligent, capable, hardened clinicians who see themselves as able to withstand just about anything - and we're seen that way by others. We do our best to cope, support those around us, carry on. But we're not as tough as we like to think we are.

Having spent a few years out on my own I now realise the importance of having a support network around me. I'd encourage major centres to reach out to our regional cousins and foster strong relationships with them. There are many vulnerable young clinicians working in some of these places who could do with a hand.

Christopher from New Zealand wrote 01-10-2014 12:41:35 pm
Thanks Todd,

I agree entirely that we could do with a better support process in ICU for consultants and those working in isolation are in most need.

However, my story refers to my junior registrar days and it is there that I see even greater risk. The first exposure to these scenarios can be very traumatising and often the supports for registrars are even worse than for consultants.

As a trainee the baseline demands are high with long, unsociable work hours consisting of rotating shifts. There are additional training demands such as the exams. In addition to that, often the trainee population is mobile in order to get jobs/experience and so shift away from family/friends and are left bereft of support. This is a recipe for disaster when exposed to the new experience of traumatic death within the workplace without having had the opportunity to develop coping mechanisms.

I think that many suffer in silence and it has potential to impact on many aspects of their lives including work performance, sleep, relationships.

I think Hannah has beautifully summarised my thoughts that we could do with a little more looking out for one another.

Sandy from United States Of America wrote 01-11-2014 06:37:56 am
Hello...I'm not a physician, but worked as a Registered Nurse in Emergency Medicine and then Flight nursing for almost 20 years so have experienced the angst of emotionally and physically challenged scenarios. There is no question this has a cumulative effect that many are unaware of until some sort of tipping point happens. I'd like to recommend a book that was a real eye opener: "Trauma Stewardship" by Laura Vandernoot Lipsky.
No question...keeping an eye out on your peers is critical, especially when a recent case has been too close to the heart (child of same age, anniversary of another event, etc). As medical professionals we are often the worst in picking things up in ourselves and even our peers. Great discussion Chris!! This is the first step to enlightening others we are not untouchable.

George Vasey from Australia wrote 01-15-2014 09:56:28 pm

Hi Chris - a beautiful post and one that is not often discussed. I work in the pre-hospital environment and am involved with the higher acuity workload. Guess what this does - exposes one to paediatric trauma/tragedy. I also come from the unfortunate position of my eldest daughter dying in a remote place in tragic circumstances as a 5 y.o. This I guess this me the perspective from both sides of the fence.

I have discovered in my journey through all of this that like you Chris, I am not a big fan of the formal debriefs – often too long after the incident and only reopens scars that are starting to heal – but it is the informal stuff that really helps. A text/call/coffee can do wonders to the person whether they are the head of the resus team or a junior. And I believe it is the fact that comforter is showing recognition of possible emotional trauma to the comforted. I think recognition is the key – the way this takes place probably does not matter as long as it is done. My involvement with organisations like SIDS and kids has shown time and again that people want their pain to be recognised.

Recently a colleague of mine was involved in a paediatric resus which was not successful. He has had 30 years in the job and half of these at the pointy end. I saw him as he came back from that job and he was really struggling. Only after I broke through his tough façade did it give him the opportunity to “let it all out”. It rocked him and did for a long time. My point with this story is that any tragic job may strike a different chord to different people. His grandkids were the same age.

12 months ago I had a terrible run of road trauma – multi casualties, teenager suicides, young asthmatic arrests, cyclist trauma arrest etc. I got to the point that I was wondering if I was able to see anymore dead people. But it was the support of my family, a line manager and a few close mates that made the difference. My faith is also of utmost importance. The contacts were casual but were instrumental in recognising that I was hurting. After the last case mentioned I went down to the beach and sat on the sand for a couple hours. I looked out to sea and gave thanks for what I have. The healing of this simple act was immeasurable. It was taking time out in this busy world. Simple. I appreciate that some people can’t do this but ones mental health is so important. You have to take responsibility for your own health - mental and physical as no one can do it as well as yourself. If I am to remain in this profession of health I owe it to all the stakeholders in me – me, spouse, family, friends, colleagues, and my patients – to keep my house in order!!
As Hannah put it -“It would be nice if we cared for each other a little more.” Next time. Put yourself out there and ask how your colleague etc. is going. It is amazing how powerful that simple act itself is. And the bonus deal you get for this act is that it may help another person whom may have unresolved emotional trauma………..!!

Not meant to be a lecture!! Sorry :)

Christopher from New Zealand wrote 01-22-2014 08:28:07 pm
Thanks George. Didn't sound like a lecture to me. All of that seems pretty good advice. Both you and Sandy have brought up the importance of context in how the reaction occurs. It is impossible to know how affected another is unless you ask and there is often unknown context that goes with a reaction.

Thanks for your book reccommendation Sandy.