Recently I had a conversation with one of our relatively new-to-ED nurses. We’d had a pretty awful shift with a tragic outcome and that night she text me saying ‘Is it normal to feel upset even when I know I’ve done everything right? It feels like I should be fine but I’m not. I keep thinking I should be strong enough to cope and that it’s part of my job’. After reassuring her that its entirely normal, even if it is part of the job I spent the rest of the evening pondering this reaction.
I had a similar conversation with one of my consultants as he went home that same evening and I thanked him for a good shift. Despite it being sad, busy and subject to the usual system pressures we had all worked fantastically as a team, given great care to our patients, and done an all round cracking job. I’d learnt a lot and had the opportunity to develop my skills managing trauma and as a team leader whilst being well supported… yet it seemed odd saying thank you for a good shift in light of tragic circumstances.
So where does this feeling come from?
It’s a cruel twist of Emergency Medicine in that in order for us to get to do our best work, someone else needs to be having their worst day (see Prof Carley’s blog here about the paradox of ED). I remember being in that same consultants’ office when I was quite new to my current advanced practice role, and discussing the fact that I had felt guilty for feeling proud of myself for independently managing a very poorly patient as he’d later gone on to have a poor outcome. He reassured me that “sometimes patients will deteriorate, that doesn’t mean you’ve done a bad job”. As usual he’s right. We only get to learn and develop, to push ourselves as clinicians, by seeing sicker patients. There will be cases where we didn’t know what the underlying problem was. There will be cases where the patient clearly hadn’t read the text book before they came in. Where you get to witness and be part of such incredible decision making and management that you feel exhilarated and remember why you chose emergency medicine in the first place (you know you’ve all seen the coffee and adrenaline poster!). Whilst you would never wish this on your patients (unless you’re a #resuswanker *) it’s when we get to do some of our most incredible work as a team.
Despite that reassurance though, it’s still something I struggle with. Indeed my last multi-source feedback had on it “Liz needs to accept that sometimes patients deteriorate and even die and this is not an indicator of poor care but a sad and expected part of clinical practice”.
So is this something all members of #teamED struggle with? And where does it come from?
Prior to ED I worked in theatres. Patients very rarely died, and if they did I didn’t know them, in that they came in asleep and left asleep. I didn’t meet their families, or talk to them, in fact it used to be quite exciting having a patient having surgery under local anaesthetic as it meant you could chat to them whilst doing the case. When I later moved to ED it meant I’d never had one of ‘my patients’ die before so I was unprepared for it and I cried on the way home or in the coffee room afterwards pretty much every time. One night in my first year there as a staff nurse we had a really tragic shift. This was pre-trauma network, out of hours in a DGH, and a patient around my age came in in cardiac arrest following a significant trauma. He didn’t make it. I can still hear his mum screaming when she was told even now. And whilst it was incredibly sad, I knew that each and every one of us in that team had done our absolute best. This patient had the best possible chance, sadly it just wasn’t enough. I sat on my break afterwards and ate pizza and cried with one of the anaesthetic trainees on the team, who I now get to work with as a consultant, as he said the same thing… we did everything we could.
That’s nearly a decade ago now and I’m still having the same conversation. And I know I’m not the only one. I’ve had this discussion with three different consultants today, and all said the same. Is it impostor syndrome? Perhaps there’s an element of that. The feeling that we’ve not done a good enough job even when we know we have.
But what about getting upset? Is that normal?
I’d argue that the day you don’t react to something tragic happening in front of you then it’s the day you shouldn’t be doing this job. I’ve seen long established consultants cry, and it doesn’t make them any less awesome. If anything it made it ok for other people in the room to cry, it certainly set me off. It’s a sign of being the team that we are that we feel comfortable enough to do so. There’s a line to be drawn though. I’ve been very close to tears when delivering bad news, and whilst its tempting to sit and cry with the family, you need to remember that this is not your grief. It’s why I personally find debriefing so very important, so you can have a brew, chat it out with your ‘family’, and then crack on being awesome at your job.
On the flip side of this, everyone reacts differently. I’ve seen spouses laugh when they’ve been told their loved one has died. I’ve seen them sit in silence for what seems the longest time. I’ve seen them smash up the resus room. There is no right or wrong way to react. The same goes for healthcare staff. If you don’t cry that’s ok too. If you want to just carry on with your shift and don’t want to sit and relive it in a debrief that’s ok. You need to do what works for you. But acknowledge that different things work for different people.
And that’s the important point here. None of us goes into work with the intention of being crap. We go in there to do a fantastic job and do the best for our patients. Sometimes this won’t end the way we want it to and that’s sad. I’m never going to tell you not to cry. But make sure you’ve got people around you to tell you you’re doing amazing, who will build you back up and encourage you to get back out there and carry on being awesome. Be that person for your colleagues, EM is a team sport and we need more people telling each other how fab they are.
And if the outcome isn’t what you’d hoped for, don’t be afraid to be proud of yourself for still doing something incredible.
*If you haven’t seen it already go to YouTube and watch John Hinds epic SMACC talk ‘craic the chest: Get crucified’… don’t be someone who wishes bad things on your patients because its cool, don’t be a #resuswanker.
RCN competencies GNP 1.3.1, 2.1.1, 2.2.3, 2.2.2, 2.2.1