Ed – This blog by Laura Howard is based on her excellent work on the impact of events on emergency care clinicians. We hope that you read this alongside the other blogs and podcasts1 the team has put together on improving the working lives of clinicians.
Laura – We all have stories.
There are those we tell to our friends proudly. I saw a patient with this and I diagnosed them with that disease, or I had a great shift today I got to do my first ever [insert procedure of your choice here]. These stories we love, they make us feel like we can help, like we have achieved something, we hold our heads high with pride when we tell them. However it is rare that we acknowledge the other side, the stories we choose not to tell. The stories that give us nightmares, and make us feel hollow in side. We all know these stories exist, though we may not understand what impact they have on us. Where and when do we process these cases?
2016 was an important and life changing year for me, my entire world was turned upside down, I was involved in three events I will never forget, the most haunting of all a maternal death. This was a case I did not want to talk about. It haunted me, it was everywhere and yet I stayed silent. The entire department knew about it, colleagues came into my anaesthetic theatre just to ask me what happened. The case was in the papers, and then of course the case was in my head, day and night haunting me. I had what I recognise now as an acute stress reaction, I was changed. I no longer thought I was strong enough or good enough to be a doctor. I was crippled by fear, I was scared of patients, especially sick ones. I wasn’t sleeping, I was all consumed by these cases. The guilt, the feeling of responsibility and the tragedy of them.
Once back on my feet and feeling well again I vividly remember finding a colleague crying in the toilets after a cardiac arrest, and another telling me they hadn’t slept all night because they think they should have scanned a patients head the shift before. Fortunately for me I had the opportunity to speak with Simon Carley, who put me in touch with Rick Body , from this and many coffees later the research project was born. As always please read the open access full text in the EMJ2.
What was the aim?
To discover how often those in Emergency Medicine are impacted long term by stories that ‘haunt’ them with a goal of discovering strategies to assist people in the future and normalise the experience. Using the expertise of a Dr C Wibberly (a qualitative researcher at MMU), Rick, Liz Crowe and I designed the research.
What did we do?
Qualitative research is perfectly placed to explore a participants’ experience of something. Collecting rich data based on how an experience was perceived, rather than an objective collection of facts. Narrative interviews allow the interviewee to tell a story based on what they feel is important to them based on their experience. During a narrative interview the participant decides what to reveal in what order, based on their own priorities and perspectives. My opening gambit for the start of all interviews was “Could you tell me about a time when an event at work has continued to play on your mind after the shift in which it occurred was over”. From there the interviewee was in control.
All interviews were transcribed in real time, replacing names with pseudonyms to ensure anonymity the transcripts were then sent to the research team. With this method, we were able to establish when data saturation had occurred. Once no new themes were emerging from the interviews we were able to stop data collection.
In total, 17 interviews were performed, with all researchers agreeing data saturation had been reached at 15 interviews. Every single interviewee had a story to tell. Chris, Rick and I immersed ourselves in the rich context of these interviews. Allowing themes to arise as we read and re-read them, we had four priori set themes (a-priori) and four themes emerged as we read the interviews (emergent themes). In this blog only the a-priori themes are discussed.
What clinical events haunted physicians?
The clinical cases recounted by interviewees all fitted into one of four themes.
Traumatic and young deaths
Traumatic and young deaths it may be assumed these are the ones we would find most upsetting and due to the nature of emergency medicine, we almost expect to encounter these cases. They were described in vivid detail, for example “she was just about alive when brought to the hospital and she was stabbed in the abdomen and guts were hanging out..” This highlighted to me how stories can stick in our minds and we continue to picture and experience them sometimes in gruesome horrific detail.
Events EPs can relate to their own lives
These are the times when we, encounter a patient and we can make a personal connection. It leaves you thinking, that could have been me or my son or my husband. These are the cases which put you in the patient shoes in a way that is all too close to your reality. For some this feeling of identification caused profound distress. For example once interviewee said “I think it is when you can draw parallels with yourself … so essentially the family circumstances were like my family similar ages, there was a girl who was my age she was about to get married, her sister and her dad…….so there was the mum and the 2 daughters to which I was like that is me and my sister and having to break bad news to them “
Bearing witness to the consequences of death on relatives
For some it is not the patient’s death itself, it is seeing the impact of that death on those around them. “When you are breaking bad news to families and you see their emotional response I find that I take that home quite a-lot, when you realise how loved that person is”. As we all know, death is the only one inevitability about life, as health care professionals this is something we are reminded of sometimes on a daily basis. Therefore, death becomes normal to us, and it is not surprising that not every death haunts us. However, we also are exposed to the very real consequence of death. “he is on his own now for the rest of his life………..I think about that more than the actual death”.
The burden of responsibility
As physicians we have a huge number of choices to make on the patients’ behalf. We choose what questions to ask when taking a history, what tests to order, how to interpret those tests, the treatment they need and finally where the patients goes after the emergency department. We try our best to rule out MIs, PEs, sepsis, and many other high-stake diagnoses. Highstakes as each choice can have life changing or life ending consequence for the patient. This responsibility is an immense privilege, and can be a huge burden. For some interviewees it was feeling the effects of this huge burden on a daily basis, a daily cause of worry and anxiety. “I was dreaming about patients and thinking about… have I checked her bloods? What if her potassium is high? What if her amylase is this? I used to phone people in the middle of the night.”.
For others, it was the constant ruminating following a negative outcome, for which they were not responsible. The fear of a mistake having been made despite the lack of evidence that there was any mistake. This is illustrated by the following quotes; “I shouldn’t have sent that patient home or I should have got them to come and see them coz I think regardless whether you have written down on a bit of paper discussed with so and so, it is still your patient and you have to take responsibility” and “I came in the next day and unfortunately, he had died in the department, and that was quite a big thing to happen. Obviously, I just thought I had done something wrong”.
Conflict in the work place
As emergency physicians we have many interactions with colleagues, in a wide multi-disciplinary team and from other specialities. Occasionally the interactions with other specialities can become confrontational. It is these interactions that haunted some interviewees. “Conversations with other specialties at times can be fraught and there are certain times where that has had a real impact on me.’
So what effect did these clinical cases have on the physician?
This section of the research was the hardest to listen to, the profound and difficult emotions felt by each participant. Despite some of these cases occurring many years prior to data collection, it was clear the lasting haunting effect some of these cases had.
For some this was a deep feeling of sadness or crying every day. There is far more powerful using the words of the interviewees, so here are some examples:
“I was driving to work in tears every day, driving home in tears every day”
“Just getting to the lowest point you can possibly get to or, or the lowest point where you could not function”
For some this resulted in a loss of confidence and self-esteem in both their home and work life.
“It had kind of a massive impact on my kind of self-esteem my self-confidence….how worthwhile I felt I was and I got kind of in a really bad way”
Alongside the emotion felt by the interviewees they also reported physical symptoms in keeping with anxiety and stress, this included vomiting, weight loss and diarrhoea. One interviewee said ‘I was actually unwell….because I was going to the toilet all the time…I was losing weight and I thought..actually…and I was being sick in the shower..”
Problematic sleep was the most commonly reported symptom. This was either in the form of problems getting to sleep, or being woken by intrusive negative thoughts. For some this was a short term effect, for others it lasted years.
“Some events were incredibly intrusive that you can’t get away from at all…so there was one period in my life when I didn’t sleep properly for 6 months which was due to clinical case which didn’t go well”
“At 3 o’clock in the morning I would be lying awake going over every patient that I had seen that night or that day……and I would be second guessing myself, I would be stressing myself out, worrying myself sick…even about simple decisions that are well within my capabilities, or even things that were simple”
“The net result of all that was, that I certainly didn’t sleep properly for three and a half years, i thought about it probably every day”
Work events intruding on personal relationships
Not only did these cases effect the individuals own health and wellbeing, interviewees also report the effect they had on personal relationships with the people closest to them.
Interviewees reported that if they had family and friends who were non-medical, they were less inclined to share haunting events they had witnessed. For some there was a concern they would not ‘get it’.
“None of the people in my life outside of work have any kind of frame of reference for any of this, this is all really weird and they don’t really know what to say and its making everybody else feel very uncomfortable”
“I think it is difficult because like my family are not medical at all but I am really close to my family but it is really difficult to talk to them about…oh I saw this today and I’m a bit stressed because this happened because they don’t really have that understanding of responsibility…they just go oh your fine”
Others felt they should not be sharing these clinical cases with loved ones who were not medical, because they wanted to protect them from such confronting stories. “Because of the nature of emergency medicine we have, we see, we do, we feel, we experience stuff which other people shouldn’t, so I don’t impose those on people who are not in this particular club. In fact, I don’t impose them on anybody.”
In order to process these clinical cases, interviewees often reported becoming withdrawn from family and social life. “I was becoming more withdrawn and I started to feel anxious at social events and gatherings amongst my closest friends and family. I had to kind of retreat in.“.
All the themes I have just described can be part of our daily lives in the emergency department. While we do not know what one day has in store for us, we can make some predictions. These cases do happen, we will at some point in our careers experience one of them. Can we teach how to process and deal with them when they do? Should we be educating our medical students about acute stress reactions? How can we help people shoulder the responsibility we carry so that it is manageable?
While reading this you may well be thinking about a case or cases that have caused you some of the experiences described by interviewees. This research has evidenced that , you are not alone. These cases happen and when they do they are tough professionally and personally. If you find yourself impacted by a case please recognise that your symptoms are probably shared, talk to someone, seek help and care for yourself. StEmlyn’s has some great podcasts on wellbeing with more to follow