Ed – This blog is the first from our friend and colleague Rusty whom you may well have met a SMACC conference, seen him online, or at the SMACC FORCE simulations with the ATACC group. This blog explores health and wellbeing from a very personal perspective, one that may well chime with you, or your colleagues. Wellbeing is a central theme of St.Emlyn’s content and we hope that Rusty will continue to explore the impact of our work on our mental health and wellbeing.
This story starts with a personal account of the impact on mental health as a result of working in emergency care. The story is a reflection on the journey from work to being unwell and the journey beyond to a place of improved wellbeing.
The Personal Story: what is distress? Rusty Carroll.
In the summer of 2016 I was writing up a Patient Report Form for a prehospital job at the nurses’ station in the emergency department of our local hospital when I noticed blood on the form. Whilst recalling the job in order to complete the form, my fist had clenched so tightly that the finger nails had cut into the palm.
The job had been a neonatal resuscitation and I had been first on scene. It was in the thirteenth hour of the fourth consecutive night shift and despite huge quantities of caffeine and sugar I was barely functioning. I initiated basic life support and when crews started to arrive, we stepped this up to advanced neonatal life support. I made a drug error. Despite asking a colleague to get the “age for page” chart out, despite them checking the dose and calling it out, I made a drug error.
I was cognitively overloaded, not just by the maths, or just the nature of the job, or just the fatigue from the shifts, but from what I had taken with me into the job: Post Traumatic Stress Disorder (PTSD). On this job, I was stressed, distressed and was suffering with a stress disorder.
What is PTSD?
In the UK, the diagnostic threshold for PTSD is high. You have to be seriously unwell to cross it. PTSD is a state of being where your threat response is turned up to maximum sensitivity for most, or all of the time. You regress from the civilised, educated and compassionate individual that you want to be, to a cowering creature in the jungle, convinced that everything is out to kill you. This state can be accurately described as hyper-vigilance.
In hyper-vigilance, your fight or flight response is permanently switched on. Your emotional response becomes anxiety, depression or anger and perhaps a dynamic and debilitating combination. This affects your behaviour, your relationships and your performance. That’s bad for your home life and your professional life. Remain in that state long enough, and despair creeps in. Despair reduces your view of your options and you want to get away from it. But where are you going to flee to? When you feel you have no place to flee to, then suicide becomes the solution for many sufferers. My own response was rage. Rage at everything. My flight or fight response is tuned very much to fight.
Is PTSD inevitable?
It is a fact that our jobs expose us to stressful situations. To be not affected in some way is sociopathic. In the immediate aftermath of a psychologically traumatic event, it is perfectly normal to have flashbacks, intrusive images, disturbed sleep, altered appetite, nightmares, mood swings, anxiety, depression or anger.
PTSD can result from a single psychologically traumatic episode, or from an insidious exposure to events over time. In my case I had exposure to a psychologically traumatic event very early in my career for which I was not prepared. Repeated exposure to similar events gradually eroding my ability to cope.
Over the days and weeks following the event, these effects should start to subside. This is the acute stress response and is perfectly normal and healthy. It is our way of trying to deal with the psychological stress of the experience, and it usually works. What about when it doesn’t?
For how long can this continue and be viewed as normal? The experts do not agree on this – their guesses range from about six to twelve weeks. So, if three months after an experience, you are still bothered by it; you may well have entered the chronic phase and require support for that. You probably would have benefited from help during the acute phase as well.
Support can come in many forms. You will need understanding family, friends and peers, you would almost certainly benefit from a work place that provides informal and formal support.
The size of this issue
The UK national mental health charity, Mind, reports that nine out of ten emergency services workers describe stress or poor mental health at work during some point of their careers (https://www.mind.org.uk/news-campaigns/campaigns/bluelight/blue-light-resources/research-and-evaluation/?ctaId=/news-campaigns/campaigns/bluelight/our-blue-light/slices/read-the-full-reports/). This is twice as high as the general workforce.
In April 2017, the UK Guardian newspaper reported that the ambulance services in England saw an increase in the number of sick days resulting from mental ill health from 35 thousand days in the 2013-2014 reporting period to over 41 thousand days in 2015-2016 (https://www.theguardian.com/society/2017/apr/02/paramedics-taking-tens-of-thousands-of-days-a-year-off-sick-with-stress?CMP=share_btn_tw). There is enough evidence here to say that this is a significant workplace related health issue.
What can be done by systems?
As this is a workplace issue, let’s take a look at what the workplace’s responsibilities might be. Here in the UK, there is legislation that we might use to frame that. The UK’s 1974 Health and Safety at Work Act states:
“That employers have the responsibility to ensure, so far as is reasonably practicable, the health, safety and welfare at work.”
It is normal to be issued uniforms or scrubs, even boots, high visibility jackets and helmets for some. It is normal to be trained to use safety equipment. It is normal to be inoculated against some infections or been offered flu jabs. That’s our physical health, safety and welfare being addressed.
Is it normal to have stress inoculation training at some point? Is it normal to have psychological coaching in to how to deal with acute stress reactions? It seems a reasonable inference from the legislation that some steps should be being taken – not just in cure but in prevention as well. As this is not universally occurring, is it possible that the approach of our employers to our psychological health might be unreasonable?
Many systems undertake various forms of debriefs and these can reduce the risk of the acute stress reaction entering the chronic phase. They can also exacerbate the risk. Whether the debrief is more likely to have a positive or negative outcome can be an indication of the culture in an organisation. In organisations where it is not ok to say you are not ok, in organisations that seek to blame individuals rather than stimulate system learning, in organisations that utilise their disciplinary pathways more than their learning outcome pathways: these are the organisations that are at risk of exacerbating the distress of their teams. Organisations that prioritise staff welfare, those that actually practice compassion as well as having it on published values posters, those that permit their teams to take the time and space necessary to deal with the emotional and psychological challenges of our work: these are the organisations that have the hope of reducing the incidence of acute to chronic degeneration. Maybe we need to spend more time looking at this, looking at ourselves and the organisations we serve.
What happened next?
What followed on from that incident in 2016? I tried to keep calm and carry on. I put on my “game face”, went to the SMACC conference in Dublin, guested on a couple of podcasts there and returned to work. I had not been sleeping more than a couple of hours a night for many months, I was comfort eating, I had intrusive thoughts and nightmares. I say that I only come out of the corner fighting, but that’s a lie. I know despair. I have had suicidal thoughts. Can you imagine how long it has taken me to both admit and to share that?
I had PTSD then. I have PTSD now, though I am not currently in a hyper-vigilant state due to many months of intensive psychotherapy and some significant life choices.
In PTSD, your cup of capacity to cope drains away one drop at a time, until you can no longer manage. You become hyper-vigilant, your stress hormone levels soar and you are on the trigger edge. You may respond with anxiety, depression or anger and maybe a combination of them. You will be fatigued, your relationships will be under significant strain and you will become a version of you that you do not want to be. You will not be coping.
You will, however, do a magnificent job of convincing yourself that everything is ok and you just need to keep calm and carry on.
You will be wrong about that.
Where to from here? Next we need to think about how we explore and recognise stress disorder in ourselves and those around us. Then we can move on to think about therapies that can help to manage PTSD in those affected and to help those who are there to support them.