“Could you tell me about a time when an event at work has continued to play on your mind after the shift is over?”

We’ve all got a story or two.

It happens to most of us at some point. Sometimes your work follows you home. A mentor once said that if it hasn’t happened to you in the emergency room, then you simply haven’t worked long enough.

I’ll share a story of mine. Nearing the end of a long night shift. A man in his 50’s, healthy, complaining of chest “burning” that he fully attributed to “heartburn”. This was my first year in practice and a busy night in the ER.

His wife had made him come in and he was seen a week before for the same symptoms. He looked comfortable, had a normal ECG, normal labs and a cardiology appointment in a day and a half. He really wanted to leave. There was a feeling that I should speak to someone about him, a nagging voice, but it was 5 am, I assumed that my colleagues wouldn’t want to see him. Should I call them at 5 am for this? In the end, I sent him home.

I went home shortly after, and when I woke up. I got an email from a colleague.

“Hey man, that guy you sent home came back a couple hours later and had a cardiac arrest in the waiting room. We got him back and he went to the cath lab. Just thought you should know.”

Everything stopped.

It was once of the worst feelings I’ve ever had. An instant “oh my god!” moment.

I dropped everything. Drove straight to the hospital. Made sure the patient was still alive with my own eyes. Apologized profusely. Berated myself endlessly.

And I didn’t sleep properly for the next month. Playing the case over and over in my mind.

A study

Recently I came across this paper, from Howard et al. It highlighted how specific clinical events in the emergency room have potential to impact our wellbeing. Both by having psychological effects and seeping into our relationships.

We all know that our work affects us in many ways. But we often don’t discuss this with each other. Are we aware of what incidents are likely to cause us the most harm? How are these events are impacting our lives?

It’s worth thinking about and discussing.

This was a qualitative study, based on the interviews of 17 emergency physicians who were asked the question at the beginning of this post.

How might you answer this question?

From the narratives that ensued, certain themes arose and were then analyzed and categorized into different groups.

What clinical events tormented physicians the most?

Traumatic or Young deaths

If you’ve ever been a part of a pediatric arrest, then you know how much these events can impact you. In this study several participants report being affected significantly by witnessing patients dying at a young age. These events remained vivid to the physicians recounting them, even if they happened a long time ago.

We know that stories like these tend to stick in our minds. They do for me. There’s a tendency to replay these events over and over in gruesome detail.

Events that are relatable to one’s life

“That person could have been me…..”

Have you ever attended to the death of a person who is the same age as you? As I get older the patients are getting closer and closer in age. Sometimes they remind me of my parents or someone I know. I’m frequently reminded of how quickly things can change.

There are times when we’re thinking more about the patient than the person in front of us. But when patients become relatable it can really bring the case close to home. Subsequently, that patient becomes a regular person, just like you, and that can impact us significantly.

I think it is when you can draw parallels with yourself … so essentially the family circumstances were like my family similar ages, there was a girl who was my age she was about to get married, her sister and her dad…….so there was the mum and the 2 daughters to which I was like that is me and my sister and having to break bad news to them “

Bearing witness to the consequences of death on relatives

It’s hard to break bad news sometimes. Knowing that what you just told a family member will change their lives forever. Seeing the impact it has on them. Perhaps thinking about what their lives will be like from now on. As a result, thinking about the consequences of death can often haunt us in more ways than the actual death itself.

The burden of responsibility

Being a physician is a huge responsibility sometimes. Patients come to us with undifferentiated complaints and ask us to make decisions that can have huge, devastating impacts on their lives.

We try our best to rule out high-stakes diagnoses in the emergency room, but we have to accept some risk. We can’t diagnose them all. Our risk tolerance varies, and for some physicians it can be a frequent cause of worry and anxiety.

I was dreaming about patients and thinking about… have I checked her bloods? What if her potassium is high? What if her amylase is this? I used to phone people in the middle of the night.”.

For others it’s the persistent rumination after a negative outcome. Even if it wasn’t their fault. For me, I know I ruminated for weeks after my bad outcome. As a result, it changed the way I felt about my practice and I struggled making difficult decisions for a long period after that.

Conflict in the workplace

It’s not uncommon to have disagreements in the workplace. Arguments with nurses, colleagues and other specialists happen from time to time. It’s a fast-paced and high-pressure environment and we are all overburdened sometimes. As a result, this can be a source of emotional distress for some.

How does this effect us?

Psychological effects

“I was driving to work in tears every day, driving home in tears every day”

Emotional distress can affect each of us in varied ways. It can make us more emotional, crying frequently.

Or we can cut ourselves off from emotion and become more withdrawn.

Traumatic events can impact our self-confidence as physicians and our self-esteem as people.

“It had kind of a massive impact on my kind of self-esteem my self-confidence….how worthwhile I felt I was and I got kind of in a really bad way”

Physical Symptoms

Stress and anxiety can manifest in physical ways as well. Participants reported weight loss, diarrhea, and vomiting. As well, our emotions can be so paralyzing that we don’t pay attention to our physical needs. Consequently, self-care becomes secondary and forgotten.

Sleep disruption

‘At 3 o’clock in the morning I would be lying awake going over every patient that I had seen that night or that day, and I would be second guessing myself,

Difficulty sleeping was the most common reported problem. Either difficulty getting to sleep or frequent awakening. Worrisomely, these effect lasted years for a few physicians.

Impact on personal relationships

For those who had partners who were non-medical, they often felt like they were unable to share their work lives and fears. A few physicians thought that their partners would simply not understand. And for others, they wanted to shelter their partners from the effects of their work. Interviewees reported becoming quiet and withdrawn from family and social life. This often was cited as a source of conflict in relationships.

“I was becoming more withdrawn and I started to feel anxious at social events and gatherings amongst my closest friends and family. I had to kind of retreat in.“.

Thoughts

Our work has significant impacts on our lives. It would be naïve to think otherwise. So if your work is impacting your life, you are not the only one. Many of your colleagues have been there or are going through similar situations themselves.

I’ve certainly been there many times, and will be back there again.

Emergency medicine is a great humbler. It’s the nature of the practice. Fast paced. Rapid decision-making. Limited information. As such, we are going to make mistakes. It’s only a matter of time.

We are going to see and do things that can be traumatic.

So how do we deal with these events when they happen?

I don’t think we talk about this enough in the medical world.

At my work, when there’s a patient death. I now take a moment to pause.

But we need to do more than that. How can we find the space to debrief after a difficult event?

Where can we have more discussions about how our work is really affecting us?

Should we be teaching medical students and residents about how to deal with acute stress when it occurs? Should we be teaching resilience? Or compassion?

We need to implement good coping strategies so that it doesn’t bleed over into our lives. Don’t try to figure this out on your own.

If you’re personally feeling the affects of emotional trauma, it’s okay. Make sure to take some time for your own self-care and compassion. Be kind to yourself and institute healthy coping strategies.

You’re not alone in this.

These situations are difficult and there is likely someone you can talk to someone about it. If you’re seeing it in someone else, encourage them to seek help.

Any other ideas?

References

stemlynsblog.org/how-events-in-emergency-medicine-impact-doctors-psychological-well-being-st-emlyns/