‘Don’t worry, everything is going to be ok, we’re all here to keep you safe’
It was normal for patients to be nervous in the anaesthetic room and so I smiled reassuringly and tried to make my eyes seem as kind as possible. I pressed the plastic oxygen mask onto her face and wondered what my own face must look like as she saw it, upside down.
The induction was uneventful; drugs, wait, tube inserted. But at the end of those sixty seconds she was dead.
What matters of her age? If she was old, or young. She came into the room with a life that I knew very little about. Suffice to say that this was unexpected. I told her not to worry, that everything would be ok.
We were four; the consultant, an ODP, our patient and I. But soon our ranks had swollen and together we tried to drag that life back into the room. Four hours later, she was still dead.
When I stepped outside a consultant commended me on my focus and team work. Could I be grateful for that?
There was no fault, but in those sixty seconds we had overseen the difference between what was alive and what was not; there will be days like this, they tell you.
People don’t tell you how to pay respect to these moments. Is it ok to not to want to remember, when I try to sleep at night, the enormity of what happened to that patient? Is it ok to need to stop myself from wondering what she had planned for her summer or what she wanted to eat when she came round from her surgery? Is it ok not to want to know who would cry for her the most?
People will tell you that empathy is the key to being a good doctor. That the ability to really see not just a patient, but a person and their narrative is the key to compassionate care. They’re not wrong of course, but what we don’t seem to want to tell each other is how to turn that tap off.
Five years since qualification, I have learned that if I truly felt the sadness and enormity of the things that passed through my hands, I would drown. It needs to be ok to talk about that.
Aoife Abbey is an ST3 in intensive care medicine in the West Midlands
Story of a tragic case describing the enormity of what we sometimes have to deal with in anaesthesia. "Just a quick whiff of gas", "you're just an anaesthetist", "is the surgeon happy with you doing that type of anaesthetic", "gosh, I didn't know anaesthetists were doctors", "my daughter didn't get in to do medicine, how long would it take for her to learn to do your job?" . Personally I blame the College people for being too insular with a narrow focus on their own committees and exams. We should have had better marketing years ago to the general public about anaesthesia and anaesthetists and a better understanding for potential trainees of how every so often they will have to deal with such tragedies - mostly alone with their ODP.
Bravo to Dr Abbey for having the courage to address this painful issue. As a fellow anaesthetist, I was called to respond to this story by writing my own blog in response (heartsinhealthcare.com/.../) and I hope Dr Abbey will take some comfort from that.
I quote from my blog,
"Rather than emotional detachment, it's healthier to relate to all of our patients with open-hearted compassion but to let go of our attachment to the outcomes. As the years go by I've learned than many factors other than my personal efforts determine the outcomes for my patients. With experience we discover there is mystery and awe in medicine, many things we can't explain. Letting go of attachment to the outcomes is not relinquishing professional responsibility, it's knowing with more wisdom and humility the limits of our efforts.
So in the face of tragedy we can offer our compassion and have the experience that deep caring and connection helps to heal our own heart too. Every act of compassion is equally compassion for the giver as well as the receiver. We can walk away from tragedy saddened by not diminished. But to sustain compassion we first have to take care of ourselves and that includes looking after our emotional and psychological wellbeing. We owe that to our patients.
What we need is a medical system that acknowledges the emotional burden suffered by doctors and provides the time and collegial support for these painful experiences to be absorbed and integrated. That process includes grieving for our patients, not pretending that we have no emotions."
I totally agree with the above comment and applaud Aoife for writing about her experience. There is a great need for protected time in all areas of the NHS for practitioners to share these experiences in a supported way. Schwartz Rounds is one approach that has helped within hospital settings. I remember many years ago, when I was a paediatric registrar working on a neonatal ICU, we held regular meetings for staff on the unit, facilitated by a psychologist, to discuss emotional issues arising from our work. This was quite revolutionary at the time, and much valued by everyone. In General Practice we can support each other through Balint groups, where these exist, or something similar. All too often we don't do this and there is a risk of emotional exhaustion and burnout. So, let's wave a flag for mutual support in protected time!
As doctors we have been pushed so far from the relaity that we have forgotten those 60 seconds Aofie is talking about. Try to imagine a scenario from my specialty where you see a patient in Psychiatry OPD and at the end of assessment with all honesty and good will you say to the patient" don't worry, I am here to help you. Just take these tablets and you will get better". The follwing morning you discover that your patient has deliberately overdosed on your prescription and died. Not easy to forget those 60 seconds of prescription writing for rest of your life and definitely not easy to forget the lengthy demoralising biurocratic investigation which starts after that unforgettable incident and all what it wants to prove is that " it was doctor's fault". All your 360s and positive achievements of past 10 years are in the bin at this stage.
Thank you Aoife for this very timely blog. We are human and I certainly think the support groups that have been suggested are extremely valuable for professionals. Fortuneately we are now allowed to express our anxieties and actively seek help .At every stage of our professional training this should be given importance and although occupational health forms do exist-the sheer work pressures of our jobs sometimes dont allow us to access this valuable source of support. The first step is actually acknowledging the need for reaching out ., and hopefully we can share some of our anxieties.
Dr Rajiv Nair
We always feel inadequate when we haven't been involved deeply or for long with a patient and then disaster happens to them. After 30yrs as a GP, I still hark back to my former partner who "showed me the ropes". She advised me that part of the job was doing bereavement visits, and just as importantly, when you make a mistake or fall out with a patient, try to talk to them and apologise for what you are responsible for. I have never been anything but humbled by the magnanimity of relatives in grief when they realise you too suffer and are upset, and that all we can do is quibble about WHEN we die, not IF we die. Jesus's advice as always is perfect "Settle matters quickly with your adversary who is taking you to court. Do it while you are still with him on the way."(Matthew 5:25). But it is not wrong to live in hope at each consultation, being the best we can be, and if disaster happens, give yourself a chance to talk about it, then move forward. We each of us need a friend's perspective and an eternal perspective to keep balanced.
That you are able to communicate such an incident in fact demonstrates that irrespective of the length of time you have known a patient, you do empathise. Despite all the knowledge, ability, decision-making you will amase over the years, disposition and true intentions cannot be taught; one is either disposed to be a carer or not. It is true the patient's age/ disease/ gender/circumstances make no difference; we choose to become doctors and rather than toughening up, we learn to be resilient with the help and support of fellow professionals and family/friends. Though grief-stricken now, you never want to remain numb and impervious to the emotive context of our profession; it is the professional relationship we develop, no matter how momentary that is the power that drives us to act on behalf and for our patients. Of course, bad consequences cause grief, but as long as you discuss the conditions leading up to the circumstances and are assured there was nothing that you could have done differently, then the grief will not be shrouded with regret. If indeed there is something to learn,mother rest assured, it will be a lesson learnt for life. Time past cannot be changed, but time passed must always prepare us for those yet to come. Stay strong, humane, resilient and empathetic! This moment too shall pass...
It is important to differentiate sympathy from empathy.
Empathy is important, what patients most need from a consultation is that the doctor understood their problem.
There is no place for sympathy in a proffessional relationship. Paternalism in medicine is dead. The problem belongs to the patient, the doctors duty is to educate and offer management options. if the doctor takes on responsibility for the patients problem then they will drown.
"Detached attachment & attached detachment - you have to develop these qualities if you want to practice medicine." Those were the first words from a professor of medicine on my first day as a 3rd year medical student. They didn't make much sense to my teenage self. I didn't think of them when I faced death (of patients) as a house officer, when I lost my patient under anaesthesia or the one in ITU or the ones in PICU... nor the time when If found myself helping with resuscitation where my loved one was a patient... I can go on. Over the years I have realised: my professor was right.
The skill to maintain a "detached attachment and attached detachment" is essential for life. I think it is inherent in our systems - 'survival'. As doctors, more so in anaesthesia and intensive care medicine, we have the luxury to hone it better. I am grateful for this very important skill which practising medicine has taught me.
My name is Maureen Tuitt I am a counselor and have been in this profession for 20 years. I have found that many clients who have experienced the above have held or suppressed feelings for so long before entering my counselling space. I believe that the greatest healing tool (as you have done) is the ability to talk about it one to one with a professional or within a group setting, this it to ensure that you are heard and can work through emotional issues. Although you are in the caring profession someone cares for YOU when something like the above happens. ....Loss grief attachment feelings of anxiety stress shame guilt are all real feelings and need to be addressed. You have survived and therefore its time to LIVE. Thanks for sharing this insightful blog. All the best to you.
A problem well worth airing - hopefully that, in itself, will have helped. In my long experience (Q1981), mostly in rather harrowing situations, I was never offered the sort of support mentioned in this string. Indeed I was not offered the time to do my regular job, let alone think about it or recover from or reflect on the bad stuff. It eats away at the soul. To allow that to happen while coping with the pressures is a gift to our patients that I think is very much appreciated by the vast majority of them.