Podcast – Moral Injury with Caroline Leech at Tactical Trauma 24

 Welcome to the St Emlyn’s podcast. I’m Iain Beardsell.

And I’m Liz Crowe.

And what a delight to have Caroline Leech back on the podcast. Long term listeners will remember Caroline taking part in the podcast, although for both our sakes, we won’t say how long ago, but it was a little while ago.

Caroline, just in case people haven’t gone back 10 years to listen to our old podcast episodes, remind our listeners of who you are and what you do.

Hello, my name’s Caroline. I’m a consultant in emergency medicine working in Coventry and I also have a long history of doing prehospital care, currently with the Air Ambulance Service and West Midlands Ambulance Service, MERIT.

And we’re at TacTrauma24 in Sundsvall and you’ve done a talk today on moral injury. Of course, I’ve got Liz with me, and this is one of those times where the less I say, the better. So perhaps I’m going to hand over to Liz to talk with you about a topic that’s close to both your hearts and terribly important to us all.

Moral injury. Liz.

So Caroline, I am very curious. In Australia we tend to call this moral distress. you called it moral injury. Some people use it interchangeably. Do you think they’re the same thing? And how would you define moral injury or distress?

I think moral injury is the strong cognitive and emotional response that can occur when events happen that violate a person’s moral and ethical code.

And I think your description of moral distress is accurate. I think distress is what we see on a daily basis. So that’s the individual case that has affected you or that really difficult day at work. But I think if those accumulate, I do believe they become moral injury. I think moral distress, there are some things we can do to lessen the impact. By the time it gets to moral injury, I think we probably do need some, professional psychological support. So, you’re right, I think those terms are used interchangeably. I think they do mean subtly different things.

 And I love that because I do think, moral injury can be an accumulation of even different sorts of moral distress that over time there’s this ethical disillusionment, about being asked or instructed or part of something that doesn’t fit with your personal or your discipline values.

Yeah, I think that’s a beautiful description of exactly what it is, yeah.

Now, you described this today, and I’m very happy to say this on air, I have given moral distress talks several times and I thought your talk today was far superior to anything I’ve ever done. But what I loved about it is that you divided it into three, categories that I’ve never heard of before.

Is this your own kind of thinking around it? Had you read it somewhere?

Yeah, I’ve done a lot of thinking about this over the years, and that comes from, I guess as I’ve got older, possibly those cases are accumulating, and I’m starting to feel a sense of unease more than I used to, and I’ve also had to support some colleagues who’ve gone through some difficult times.

And yeah, I’ve I just thought of a way to present it because you often hear people talking in recent times about the moral injury of the pandemic, and that’s one way of looking at things, but it doesn’t really capture what we have on a daily basis, and particularly the focus of this conference, I was thinking about emergency service responders, whether you’re police or fire or, pre hospital teams, ambulance service teams, and I was trying to make it applicable to them rather than, the sort of in hospital setting.

 So, you described three perhaps mechanisms of moral injury. The first being acts of commission, the second being acts of omission, and the third being betrayal. Can you take us through the three because I think this is something that will really resonate for our listeners in a way that perhaps they’ve not been able to connect or perhaps associate themselves or others as having moral distress or moral injury.

So, acts of commission, I would describe as something happens, which shouldn’t have happened. Acts of omission is perhaps something should have been done, but it didn’t happen. And betrayal is much more on a sort of systems and organizational basis where you wanted to deliver some care to a patient and you were not able to, and it was outside of your control. So if we start off on the first one, then, The examples that I gave are some things been done that shouldn’t have happened, and actually today we heard, an amazing talk about, a firearms officer who, in a very difficult hostage negotiation situation, the hostage was wounded. and so that would be considered an act of commission. So, something’s happened, which should never have happened. And obviously you can’t even begin to imagine how that officer would have felt. But most commonly in certainly in my prehospital and emergency medicine practice, we bear witness to really horrible things happening. And the sort of example I gave was of a drink driver hitting a patient and then speeding off and not being brought to justice, and that really makes us feel angry, and it also gives a really distorted view of the world.

I’ve got friends who are not in the emergency services and many of those have never seen a dead body. So, until their parents or grandparents die, that’s not an experience they’ve ever had. And yet, when I think about my job, I see a cardiac arrest probably every day and especially when I work on the air ambulance, and we are specifically tasked to support those cases.

And so, I think, we just have to be really mindful that, our experience is different, and we have to be careful that we’re not viewing things through a different lens because we are exposed to this level of suffering.

So this is where I think you are adding a new dimension, to what previously exists in the literature, because often moral distress or accumulated moral injury, is described as being asked to do something, that goes against your ethics, but what you’ve talked about is this distortion or disillusionment or being confronted that humanity, that not all people do act in a humane way.

That cumulative effect of being exposed to constant domestic and family violence, the distortion of having to treat a patient that you know is going to go out and do the same actions repeatedly over and over again. That actually, can cause moral injury, which I’ve never heard of before and I think it’s giving a language and perhaps even a framework for us to be able to recognize what was said. And the other critical thing I think you said today was, being able to name these things is very helpful. One of my favourite phrases I use all the time is, name it to tame it. Once you can conceptualise what it is that’s actually causing you harm, it means there’s a point of intervention.

And so that’s why I just absolutely loved the way you talked about this today.

 So, should we move to number two then?

 So, this is acts of omission, so something should have happened, and it didn’t happen for whatever reason. And the two examples that I gave were number one, you were performing a pre hospital emergency anaesthetic and you couldn’t intubate that patient and, you then reached for your supraglottic airway, but there wasn’t one in the bag, which should have happened and what didn’t happen. And then you get to hospital and the anesthetise at the hospital intubate without any problems whatsoever. And that patient goes on to die. And actually, if you were an outside person, you’d go, they had a non-survivable injury.

But on your mind, is the fact that you didn’t intubate that patient and there wasn’t a supraglottic airway and you failed, and you feel great guilt and shame about that. And I guarantee there will be prehospital providers and emergency providers who that will resonate with them and they will think of numerous examples of where things have gone wrong, and they weren’t able to deliver the care they wanted to deliver or they made mistakes in their judgment.

The other example we gave was around, should you perform a resuscitative thoracotomy, or should you perform a hysterectomy and what if you decide not to? And then later, in the debrief someone says, “oh no, actually I think I would have done under those circumstances”. And you think, oh my gosh, Have I lost that patient their chance of survival?

Yeah, and they make us feel really guilty, really ashamed. And I think of all of the causes that we’re going to talk about, I think they’re the most difficult because they’re often very personal and they’re very unique to the individual. I can think of some cases myself from the past that I, that still probably affect me today, because I feel very guilty about what happened.

I think everybody’s got those cases. We try and bury them somewhere deep, but they’re a wound that can easily have that scab picked off by a memory, a similar case, someone else being harsh. And I think the thing that is important to talk about here is, first of all, be compassionate and gentle with yourself and with others. And to think about, once we know the outcome of something, oh, it’s all so obvious what we could have done differently, but that we’re making decisions in a very dynamic, complex, fast action pace, and that everybody really has come to this with a good intention.

But I remember in my PhD, a number of senior clinicians saying, how they often think back to how science has come along and if they’d only been more clever, they’d only be more intelligent if they’d only had that piece of information now, all the lives that they could have saved. That could be a moral injury.

Yeah, definitely.

The other one I want you to talk about though, is when those really unhelpful comments are made in M&Ms, in ward rounds, in handovers, of could’ve, would’ve, should’ve, that leave a lasting impression.

There’s the sort of hot debrief of these cases, and then there’s the sort of later case reviews and M&Ms and, if you’re feeling bad about a job already and then people have lots of comments to make about it, and even if they are coming from a position of non-judgement and kindness, just very subtle changes in the language can make you feel even worse.

 Certainly this is something I’ve reflected on, as I’ve become older and more senior, and I’m supporting colleagues, and even the subtle comment, “Oh, I would have done this”, or, did you consider doing this?” and, they’re all meant we’ve got to improve, we’ve got to always be better, we’ve got to learn from these cases, but I’ve almost think like we should be going on courses to learn how to communicate in this scenario because it’s so sensitive and it can really change how somebody processes this and then is able to move on. Or is it actually sticking out as it as a problem?

And there’s a balance to be made here, isn’t there? Because I’m a huge fan of debriefing, but I never ever let people who are not involved in the debrief attend. They weren’t there, they don’t know. that’s very easy to make those sorts of comments. And we don’t want to shy away, I think there can be great harm done by making that same mistake at some point in the future, but we have to be so compassionate and mindful that everybody has done the very best that they can. And the learnings can come. They don’t have to come 30 minutes after the event, or an hour and a half after the event when someone who’s exhausted walks in the door and someone from the tearoom goes, oh, I heard you’re involved in blah.

 I think one of the problems though, I know your job, you’re employed to, lead that debrief. You weren’t involved in the case, but you’re going in as professional, and you’ve been trained how to do this. But often like selling the UK NHS, it would be me as the consultant who was involved in that job who has to debrief because there’s no one else around, we haven’t got much time. and actually, I’m the person that might need to be debriefed as the consultant. I don’t think we’ve always got it right. And it’s certainly something that I think we need to reflect more on, when particularly if we’re leaders of organizations and thinking how are we doing this and how are we supporting our teams the best we can be.

And just to clarify, I don’t lead hot debriefs, I would be brought in for a cold debrief, but it’s this whole thing about, why do we not provide coaching, supervision, support? Why do we not encourage people who are leading people through very complex, often distressing and confronting cases?

All right, let’s get to number three. And this is Betrayal. Betrayal by whom and about what?

So, the example that I gave here. We work in the emergency departments in the UK at the moment and we have no beds in the hospital. They are full to the brim 103 percent and in fact, we’ve got extra patients on each ward. We’ve got ambulances queuing outside and worst of all probably, is we’ve got patients in their 80s and 90s years of age who are sat in the waiting room for 24 hours and they’ve been seen, they’ve been treated, they’ve been clerked by the medical team, they’re just waiting a bed. And that to me and to my colleagues is completely unacceptable. That is not okay, but we literally have nowhere else to put these patients. And we start to think, actually, should we put them in a bed on the corridor? Is that actually better? And, but no, that’s abhorrent as well. So, through reasons that are out of our control, we are unable to deliver what we believe to be good care. And we are embarrassed, and we are ashamed. And what then starts to really upset me is people have stopped complaining. So, like the relatives and the patients, don’t complain like they used to because they’ve realized as well, this is a situation, the doctors and nurses are doing the best that they can. And that to me, feels even worse. that’s an example. We could also talk about the pandemic and the British Medical Association did a survey of doctors in 2021, which you can imagine that was a point where they felt very betrayed that they didn’t have the PPE. They weren’t allowing families to be with loved ones when they were dying. They didn’t have enough time to spend with people. So, that would be an example were betrayal. Because you’ve not been able to do the job that you wanted to do. And that could be in an organisation as well. It could be that the constraints of your organisation don’t allow you to do the job that you want to do.

I think that having that framework, and to be able to think about those three things is really powerful because if you can name it to tame it, if you can target in on what it is, you can think about what’s in your realm of control or not, or what might be a helpful intervention. And I think with some of those commissioner and omissions, being able to sit down with your team and say, I’m feeling this, this is hurtful too, or how do we advocate, or how do we create change. Or how do we survive and know that we can’t do everything that we want to do, even though we have that intention, can be very powerful?

It’s been an utter joy to listen to you both talk and I’m sure all our listeners have got just as much out of as I have sitting and listening to two true experts who’ve clearly thought this through.

There’s a lot of thinking to do but to listen to you both reminds us that this is so important, and I hope listeners will take this back to their own departments and consider how they can just make things a little better. Caroline, it’s a joy as ever to see you. I hope it won’t be another 10 years before you’re back on the podcast again and thanks so much for joining us.