I started thinking and writing this blog about 2 years ago, but I’d not really been happy with understanding how I feel about it. More recently I’ve been asked to prepare a talk for the Don’t Forget the Bubbles conference in June 2019 on the way that we deal with procedures in the ED. It seemed like a good time to revisit the concepts ad to ask myself again with a great day in the ED is a paradox.
At the heart of emergency medicine is an uncomfortable paradox, a tension perhaps, a mental state that permits us to operate in an speciality filled with the highs of success and the pits of despair. The paradox of our practice in the shadow of the lived experience of our patients and their families.
I was recently in resus when the standby phone trilled in the background. The message? 22 year old pedestrian vs car, hypotensive, GCS 10, head, chest injuries and a fractured femur. As this was read out one of my colleagues declared ‘Awesome’ and punched the air in anticipation of a major trauma patient coming to our resus room. It was not just them either, the nurses and doctors were animated in preparing for what was to come. ‘Should we get the thoracotomy tray ready?‘ asks the resus room lead, a question answered with a mix of excitement and disappointment, ‘let’s hope so, I’ve never even seen one, but I guess if this is blunt trauma they may not need it’.
How strange it is for our colleagues to be talking about a patient who is clearly having the worst day of their life (1-3), perhaps even the last day, with a sense of such excitement.
Hold that thought for a second and ask yourself if you too get that frisson of excitement when the standby phone goes and you hear that something ‘juicy’ is coming through the door in a few moments. For many if not most of us in emergency medicine I suspect that this will be you, it’s time to get into resus mode, to stimulate your inner resuscitationist and put on your game face
These are days and patients that we look forward to, the big resus where we have the opportunity to make a difference, or even if we can’t influence the outcome to ‘do stuff’. We generally enjoy doing procedures. It feels like we are providing some benefit, and in the vast majority of circumstances it makes us feel good to do it, to demonstrate and practice our skills and to some extent, and this may be hard for many of us to admit, to be seen to be doing it. As by being seen to perform we can be admired and put on a pedestal as someone who has the skills, the training, the permission to do what for most people will never be a part of their world.
The patient perspective.
What seems to get lost in the heat of the moment is the impact of our interventions on patients and their families. This is arguably a paradox that extends right back to the selection process for medical school. We try and select people who have a real desire to alleviate suffering, to help people and in the eyes of some commentators to feel genuine empathy for our patients and that does indeed happen. However, there are times and circumstances where this is arguably not possible. As a junior paediatrician I spent a lot of time, with colleagues and parents, holding down wriggly screaming children whilst I inserted needles into their arms in the pursuit of a vein. I still do the same, which in isolation is a long way from the caring, kind, empathic and gentle aspirations I had when I first thought about having paediatric emergency medicine as part of my life.
It’s the same whether you are attempting an LP in a child or in sedating a combative head injured patient, it’s still a far cry from the patient perspective. What we do to patients is often painful, uncomfortable. unpleasant and in many cases has the potential to cause significant harm or even death.
In a SMACC talk on dying Alex Psirides (10) put up a slide about the difference between the clinicians perspective and that of the patient. It’s always struck me as a really good way to think about procedures in the ED/PED.
I’m wonder how this would look for you? Perhaps you’d like to create your own and fill it in based on your individual experiences and the patients you treat. For my PEM practice the slightly tongue in cheek version looks a bit like this.
The naive perspective
It’s not just about ourselves, patients and families though. As senior clinicians we can have a tremendous impact on those around us through our behaviours, comments and actions. In the ED I look after the 3rd year med students coming through the department on 4-week rotations. It’s a highly sought after rotation and it gets great feedback but the experience of the med students is complex. On day-one almost all of them express the desire to do procedures. They want to cannulate, catheterise and to perform CPR. In part because these need to be ‘signed off for assessment purposes’, but you can see the desire to be part of the club of people who ‘do stuff’.
More often than not the experience of ‘doing stuff’ is complicated by the emotional entanglement of the procedure paradox. After the first attempt at CPR, especially when the outcome is death they often feel a whole mixture of emotions that range from excitement and achievement through to sadness and even shame. The shame of wanting something bad to happen such that they can benefit from the experience. Our induction and our debriefs now take account of this and we endeavour to always ask people how they feel, not just how things went. My advice would be to do this as often as you can. You’ll gain some real insights into the paradox if you do.
This is of course an issue that affects all people who work in emergency settings and is perhaps most obvious when we look at painful procedures in children. There is a fair bit of evidence out there that holding children for painful procedures is distressing for carers and for clinicians, especially junior ones (4-9).
Every procedure has two indications.
There are two reasons to do any procedure. Firstly the patient may require it. Secondly you might want to do it. Only the former is acceptable. John Hinds put this really well at SMACC when he asked us to ask of ourselves before embarking on a thoractomy ‘are your intentions honorable’ (11).
This is great advice and really important when resuscitations progress beyond the point where meaningful survival is possible. I’ve been in situations with penetrating trauma patients with documented asystolic cardiac arrest for >60 mins where I’ve been questioned for not performing a thoracotomy. Thoracotomies are exciting, challlenging, complex, dangerous, thrilling even, but those are all emotions and stimulants for the operator and the team, but that’s never an indication to progress.
But it’s practice isn’t it?
When I was a med student and junior doctor it was common practice to reintubate the recently deceased for training purposes. No consent, no publicity, no awareness. It was a practice of its time although I don’t think it happens here in the UK anymore. Ethically we have changed, and we now have simulation to help train ourselves. We now have online learning, simulation and cadaveric courses for pretty much anything and so the justification for performing any procedure in a futile situation in the pursuit of learning is……..well just wrong.
Are we really terrible people?
If you’ve made it this far (Ed- well done) then perhaps you’re a little bit challenged. You no doubt see yourself as a good person who wants to do the right thing. You’ve worked hard to get to where you are and you certainly don’t inflict pain or discomfort to patients without good reason. You feel that you are a good person (and you are).
I first started thinking about this seriously after a particularly traumatic thoractomy in the ED. It was a borderline decision as to whether we should do the procedure, but the patient was young and we were a little unsure what the downtime was. It was a stressful moment and I remember being at what I thought was at the peak of the Yerkes-Dodson curve when I made the decision to go for the thoractomy.
The thoractomy was brutal, violent, disruptive and bloody as it always is. It was also ultimately futile, as again it often is. The case and the decision to perform the thoracotomy received criticism from those not in the room at the time on whether it was indicated. That incident and others similar to it have forced a reflection upon me that’s been simmering for years. I know that I’m not alone in this place. I’ve spoken to plenty of other clinicians who can describe the same thoughts and emotions from similar cases.
Recently I spoke to a psychologist about this anxiety and what I perceived as a paradox in the expectation that she would be surprised and shocked out out apparent belief that a great day may include carnage. I wondered if she would find some sort of underlying psychopathy or personality trait amongst critical care clinicians that would explain this behaviour and that it would be regarded as abnormal. I was suprised at the response. Her view was that there is absolutely nothing wrong with wanting to be good at what we do. The fact that what we have to do is sometimes brutal, painful or unleasant is not a feature of us, but rather a feature of what we do. As long as our intentions are honorable at the point at which we decide to perform the procedure, then there is nothing wrong with wanting to be there when the procedure is required.
What really struck home is this phrase…
‘As a non-critical care person I am so glad that there are people out there like you. If I get knocked down by a bus tomorrow then I want to be treated by someone who is good, maybe even slightly obsessed with getting it right, with wanting to do what is needed. Can you imagine if the person treating me was distracted by an emotional torment of whether they should or not be feeling energised by being there. I just want them to be there, and to be good’
This blog is designed to make you stop and think about how our desires and ambitions to learn, to demonstrate and to achieve procedures in the ED might stand as a paradox to what we hope to achieve for our patients. I hope it’s made you stop and think about your own motivations and that it helps us understand that the paradox is real, but also that it’s a good thing.
I would urge you to look out for it in yourself and in colleagues, and in particular for those in the formative weeks and months in emergency medicine. They may need a little time and support in navigating a way through it.
A few final thoughts to reflect on.
- We are energised by utilising our skills in trauma situations, we are not energised by suffering, this does not make you a terrible person.
- We don’t wish harm on others, but we paradoxically enjoy it when it leads to us being required to actualise our skills and knowledge.
- The most dramatic and clinically satisfying days of our careers may be the worst day of our patients and their families lives, it may even be their last day, and that should never be forgotten.
Thanks to the St Emlyn’s team for their advice on this one and especially to Liz Crowe who is an expert in this area. You can read more from Liz here.
- ‘It’s turned our world upside down’: Support needs of parents of critically injured children during Emergency Department admission – A qualitative inquiry. Wiseman T, Curtis K, Young A, Van C, Foster K. Australas Emerg Care. 2018 Nov;21(4):137-142. doi: 10.1016/j.auec.2018.09.002. Epub 2018 Oct 23.PMID: 30998889
- Experiences and needs of parents of critically injured children during the acute hospital phase: A qualitative investigation. Foster K, Young A, Mitchell R, Van C, Curtis K. Injury. 2017 Jan;48(1):114-120. doi: 10.1016/j.injury.2016.09.034. Epub 2016 Sep 23.
- The experiences, unmet needs and outcomes of parents of severely injured children: a longitudinal mixed methods study protocol. Foster K, Curtis K, Mitchell R, Van C, Young A. BMC Pediatr. 2016 Sep 6;16(1):152. doi: 10.1186/s12887-016-0693-8.
- Caregivers blinded by the care: A qualitative study of physical restraint in pediatric care. Lombart B, De Stefano C, Dupont D, Nadji L, Galinski M. Nurs Ethics. 2019 Apr 11:969733019833128. doi: 10.1177/0969733019833128. [Epub ahead of print]
- Holding and restraining children for clinical procedures within an acute care setting: an ethical consideration of the evidence. Bray L, Snodin J, Carter B. Nurs Inq. 2015 Jun;22(2):157-67. doi: 10.1111/nin.12074. Epub 2014 Jul 23.
- A qualitative study of health professionals’ views on the holding of children for clinical procedures: Constructing a balanced approach. Bray L, Ford K, Dickinson A, Water T, Snodin J, Carter B. J Child Health Care. 2019 Mar;23(1):160-171. doi: 10.1177/1367493518785777. Epub 2018 Jul 13.
- Holding children for procedures: An international survey of health professionals.Bray L, Carter B, Ford K, Dickinson A, Water T, Blake L. J Child Health Care. 2018 Jun;22(2):205-215. doi: 10.1177/1367493517752499. Epub 2018 Jan 21.
- Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians.Svendsen EJ, Pedersen R, Moen A, Bjørk IT. Int J Qual Stud Health Well-being. 2017 Dec;12(1):1363623. doi: 10.1080/17482631.2017.1363623.
- Nurses’ perspectives on supporting children during needle-related medical procedures. Karlsson K, Rydström I, Enskär K, Englund AC. Int J Qual Stud Health Well-being. 2014 Mar 12;9:23063. doi: 10.3402/qhw.v9.23063. eCollection 2014.
- Hinds J. Crack the Chest https://smacc.net.au/2015/10/hinds-crack-the-chest-get-crucified/
- Psirides A. Everything at the end of Life. https://smacc.net.au/2018/03/everything-end-life/https://smacc.net.au/2018/03/everything-end-life/
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