Primary Survey July 2017

Last winter was a difficult Winter for Emergency Medicine (EM), ED and the staff who work within them. The unacceptable pressures that faced us have only partly gone away and many of us have probably not fully recovered. Stress levels were high, dissatisfaction wide spread, the patients kept coming, and few appeared to leave.

As the year rushes by and Winter can be seen on the not too distant horizon, this themed issue of the EMJ is timely and of significant relevance in focussing upon stress, psychological well-being and job satisfaction amongst a range of Emergency Department staff from both within this country and abroad. Four articles examine this subject and are supported by an excellent commentary from Liz Crowe and her colleagues.

Emergency medicine is a great career:

The first article is a qualitative narrative study interviewing a small number of Consultants from a variety of large EDs in Wales. The study was undertaken to deter- mine their views on both the positive and negative aspects of their jobs and to inform prospective trainees of the attractions of a career in EM. Reassuringly, and despite the pressures of the job, most Consultants were positive about EM, citing a range of factors to justify their opinions. Perhaps surprisingly, all were positive about a Consultants work-life balance, a view contrary to that held by both EM and non-EM trainees, a view that we need to promote to all students and trainees to consider EM as a viable career option.

EM consultant well being

The second paper by Fitzgerald et al is a further qualitative study, this time of a larger representative group of Consultants from the South West of England. The authors this time set out to determine the perceptions that EM Consultants have of their psychological health, factors that impact on this and how they attempted to cope with the pressures of being an EM Doctor. There is much within this paper of importance but for me the negative effect of external organisational issues on the well-being of EM Consultants stood out. This paper should be read by managers as well as Emergency Medics.

A view from abroad

Demonstrating that stress and job dissatisfaction are not unique to UK Emer- gency Departments, the paper by Jiang et al examines the rates of career satisfaction and burnout in a large group of ED nurses from China. In a questionnaire survey with an impressively high response rate, they showed that despite a relatively high percentage of nurses being satisfied with their jobs, there was a high level of burnout with worryingly, almost one in four nurses stating that they were likely to leave their job in the next year. While there may have been some cultural differences behind these findings, the study clearly showed again the relationship between the working environment and levels of stress and burnout.

It’s Not Us, It’s the Organisation

Finally, the systematic review by Basu et al from Sheffield brings together the existing literature on organisational issues that may negatively impact on the psychological well-being of ED staff, as well as adversely affecting their ability to care for their patients which ultimately results in burnout and early retirement. The authors decided to focus on organisational stressors rather than individual vulnerabilities as they felt that these were more likely to be amenable to change. The review found that, common to other specialties, high workload and work intensity as well as long hours negatively impacted on the staff’s psychological well-being and feelings of burnout. In addition, low levels of support from managers and non-ED colleagues, lack of professional recogni- tion and lack of educational opportunities were all important additional contributors not only to psychological well-being but also to compassion fatigue and the ability to care for our patients. While the authors found that studies examining interven- tions designed to alleviate organisational stress were lacking, the evidence presented provides an excellent base to develop interventions at an organisational level to support all ED staff, both in the short term and the long term.

The positive effect of GP’s reducing ED attendances

Undoubtedly one intervention that helps all ED staff is a reduction in the numbers of patients that are seen within an ED. An interesting study from the West Midlands examined the effect of a pre-hospital partnership between ambulance staff and GP’s. GP’s, according to pre-defined call criteria, either provided telephone advice and support to paramedics or attended patients at scene. Almost 10% of calls were able to be handled by GP’s with 80% of these patients not requiring subsequent transport to an ED. The sustainability of this project is supported by it continuing to function 4 years after its initiation.

Too hot, too quick

There appears to be increasing evidence that higher oxygen concentrations during resuscitative processes may lead to harm. This now appears to extend to the use of external exothermic warming devices used pre-dominantly in the pre-hospital setting. I must admit I wasn’t fully aware of these devices designed to externally warm patients, let alone being aware of the oxidative chemical reactions that are used to generate heat. In a neat mannequin study, designed to simulate the use of higher concentrations of inspired oxygen in an enclosed environment, the study by Brooks and Deakin clearly shows that the use of higher inspired oxygen concentrations not only accelerate the exothermic reactions used in the warming devices but result in excessively high temperatures that may lead to clinically significant burns.

Why Patients take the bus

Finally, a paper from Australia, examining the effect of a public health campaign on the use of Emergency Medical Services to transport patients with an Acute Coronary Syndrome to hospital. While the majority of patients with an ACS recalled seeing the campaign, disappointingly the campaign appeared to be unable to influence patients’ behaviour, with over 40% of patients using alternatives to EMS, believing them to be faster than waiting for an ambulance. The authors conclude that further efforts are necessary to inform the public of the medical benefits of EMS transport.

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Richard Parris

 

 

Primary Survey June 2017.

This month’s editor’s choice is actually a pair of papers: one, a study on the diagnostic characteristics of the T-MACS chest pain risk stratification score AND the other, a paper explaining a key methodological concept used in this and other studies of diagnostic tests, the receiving operator characteristic ROC) curve (Richard Body (an associate editor of EMJ) and colleagues previously developed the MACS rule, which classifies patients as very low risk or very high risk after the results of an initial set of biomarkers are known, TMACS relies on obtaining both high sensitivity troponin and heart-type fatty acid, but the latter biomarker not widely available. A modified rule, the MACS score, uses only high-sensitivity troponin and in the current study the authors evaluate this new rule’s test characteristics, using the ROC curve. Hui Zhe Hoo, Clinical Research Fellow at the University of Sheffield and a respiratory physician, explains the fundamentals of the ROC curve using this paper as an example. This is the third in EMJ’s occasional series of articles explaining statistical concepts frequently found in the emergency medicine literature.

Still a cinderella service

Demand for mental healthcare in the ED continues to rise. Sadly this rise increasingly includes children and the provision of child and adolescent mental health services (CAMHS) in most emergency departments falls well short of what is needed. Thus, a systemic review in this issue by Newton and colleagues from Canada on children’s mental health crises in the ED makes interesting reading. A previous review undertaken by these authors in 2010 provided some evidence to support the use of specialised care models to reduce hospitalisation, return ED visits and length of ED stay. In the current study they report increase in research over the past few years, yet most of the evidence is limited by weak methodology. It is evident that the specialised resources and skills needed are still not readily available and the authors reiterate the need for high quality evidence to guide mental health screening, early and effective interventions and on-going follow-up care after an ED visit. I suspect few of us would dispute this view.

Ladders or smiley faces?

Accurate assessment of pain due to an acute injury can be challenging especially when the child is distressed and anxious, but providing timely and effective analgesia is key to child and carer comfort and satisfaction.This issue includes an interesting paper by Ffion James and colleagues from Wales who set out to assess the inter-rater agreement of the Royal College of Emergency Medicine (RCEM) composite pain scale. The majority of pain assessment tools for children were designed for post-operative or chronic pain and not for sudden and acute pain due to injury. The RCEM composite tool combines the numerical rating scale (Ladder), a modified Wong –Baker Faces Pain Scale (Faces scale) and a Behaviour score which groups pain into four categories based on severity. To date the reliability of this scale has not been assessed. In their study, pain severity was assessed by the triage nurse doctor and child (depending on their age) using the composite pain scale. The Faces Scale demonstrated greater inter-rater agreement than the Behaviour Scale, while the Ladder demonstrated poor inter- rater agreement in comparison with the Behaviour score. The authors conclude the Ladder score could be omitted from this composite tool.

Using emergency data for public health interventions

Two studies in this issue demonstrate how data from emergency care can be used to inform public health interventions. Acute and chronic alcohol intoxication, a worrying global public health issue, is the cause of many health and social problems. Reunion Island in the South West Indian ocean is no exception. Reunion Island is among the four French regions where premature mortality due to alcoholism and cirrhosis is the highest and foetal alcohol syndrome is seven times higher than that of metropolitan France. Vilain and colleagues undertook an exploratory analysis based on syndromic surveillance data to describe the emergency department visits for alcohol intoxication and factors associated with their variation. Alcohol intoxication attendances were the second most common reason for ED attendances after trauma and these attendances increased significantly on benefit payday, weekends and public holidays. The authors conclude this kind of syndromic surveillance system for monitoring public health data other than infectious diseases can be used to inform initiatives to reduce morbidity and mortality from alcohol intoxication.

According to the WHO, interpersonal violence accounts for around half a million deaths a year globally. This figure will come as no surprise to ED clinicians and may even be regarded as conservative by those caring for victims on a daily basis. Addressing violence has traditionally been a police concern, so it was interesting to read of a cross sectional study by Quigg and colleagues in the UK which explored the potential of ambulance call out data in understanding patterns of violence to inform prevention activity. This paper is well worth a read as ED’s will see similar trajectories and trends. The majority of call outs were at night for young males in deprived and urban areas, and these calls increased on weekends and bank holidays but not for sporting events. 77.3% were assault/sexual assault while 22.7% were stab/gunshot/penetrating trauma. Interestingly, there were significant differences in call out characteristics between the two violence types. The authors conclude that ambulance call out data provides a rich source of information and sharing this data could be key in violence prevention programmes. Any information that can contribute to violence prevention programmes has to be worthy of consideration.

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Mary Dawood

 

‘My Mental Toughness Manifesto’ Part 4: PROCESS

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Everything in aviation we know because someone somewhere died… We have purchased, at great cost, lessons literally bought with blood… We cannot have the moral failure of forgetting these lessons and have to relearn them.”

Sully Sullenberger
Pilot of Flight 1549, ‘The Miracle on the Hudson’

All frontline healthcare warriors will bear scars from emotionally distressing experiences in the workplace (e.g. major incidents with multiple casualties, unsuccessful paediatric resuscitations, personal mistakes resulting in patient harm). For the most part, members of the public will only rehearse being exposed to these flavours of horror by watching movies or having nightmares. For us, it is a potential reality every shift.

In the aftermath, the way one processes these events heavily influences future commitment to similar causes and cognitive appraisals (challenge vs threat mindset) – the key determinants of mental toughness.

Adaptive processing should incorporate ‘Black Box Thinking’ and self-compassion. 

‘Black Box Thinking’

BBT betterConsider the aviation vs healthcare discussion for a moment – arguably the two most safety-critical industries in the world.

On average, just one commercial flight goes down for every 8.3 million take-offs worldwide. In the US alone, there are approximately 400, 000 avoidable medical errors every year, which is the equivalent of two jumbo jet crashes every day [1, 2]. That is a gargantuan discrepancy in passenger versus patient safety.

Of course, it is well documented that the two industries are not directly comparable. There are far more reasons for a patient to die than there are varieties of plane crash, and medics do not yet have the option to switch on a mental bandwidth-sparing machine that’s able to mop up routine tasks. Nonetheless, the statistics illustrate an indisputable point – we have a huge amount to learn from our aviation counterparts, whether we like it or not.

Why is aviation such a staggeringly high performance industry? The answer is simple: there is an institutional culture of learning from failure. Every plane is equipped with two sturdy black boxes which record conversation in the cockpit, and electronic decision-making (i.e. which buttons were pushed). In the case of an accident, the black boxes are promptly retrieved from the battered fuselage, opened, and the contained data interrogated. Every aspect of the crash gets the fine-tooth-comb-treatment to identify exactly what went wrong. Protocols are subsequently modified so the same mistake can never happen again. Error is not viewed as a sign of weakness or inadequacy – on the contrary, it is treated as a precious (even exciting) learning opportunity for everyone who might benefit.

Healthcare culture is largely the polar-opposite. Failure is stigmatised because doctors are supposed to be infallible in the eyes of the public. Mistakes get ‘swept under the carpet’ by the guilty to avoid being held accountable and where that is not possible, the blame-game ensues [3]. When one’s professional credibility is at stake, a successful escape from the situation is higher up the priority list than learning from the failure; and the omnipresent threat of litigation only serves to further entrench this defensive, maladaptive institutional culture. The immediate gratification of reputation-preservation trumps the potential for professional growth that naturally follows acknowledgement of personal failure. We routinely blind ourselves to the best possible signposting for getting better at our jobs – our mistakes.

Whilst this growth-stunting phenomenon will vary in severity across the spectrum of healthcare environments, you would be hard-pressed to find a doctor, anywhere in the world, not regularly exposed to this embarrassing peculiarity of our profession.

Be a black box thinker. Own your mistakes. Share your lessons. Interrogate every performance with the curiosity and tenacity of the Air Accidents Investigation Branch. Re-conceptualise your relationship with failure so that it no longer represents an existential threat, but acts as a guide for your ‘practice’ phase.

‘Reflective practice’ is an overused and misunderstood term in medical training (in my opinion). Often, written evidence of it is a requirement for career progression, and when one ‘reflects’ for that reason alone, it ceases to be useful. Furthermore, documented reflections will too frequently centre around what went well – a less lucrative training exercise.

Apply the black box philosophy to your reflective practice and force yourself to face potentially ugly truths. Embrace being criticised and never back down from asking a ‘stupid question’ – it tees you up for focused training and subsequent accelerated improvement. Have the bravery to be the detective leading the warts-and-all investigation on yourself.

Self-Compassion

In frontline healthcare, we are routinely exposed to life-changing injury and acute illness. If we take our workplace goggles off, and dare to view the worst aspects of our jobs through the eyes of a ‘normal’ person, it can be intensely disturbing. Furthermore, subscribing to the highest professional standards can make us prone to gratuitous suffering as we’ll mistakenly convince ourselves that we could have done more for unsalvageable patients. Our keenness to take full responsibility can render us vulnerable to unnecessary self-punishment.

Without appropriate perspective and personal support, our view of the world, and indeed of ourselves, can become warped. Long-term self-neglect in our line of work will eat away at our commitment to the job, potentially invite long-term psychological damage (PTSD), and ultimately, harm our patients.

When a particularly traumatising incident occurs, many institutions will employ a ‘critical incident stress management’ (CISM) protocol, which encompasses a range of supportive interventions aimed at preventing PTSD [4]. This includes a formal group debrief, led by an outside party (usually a psychologist), within 72 hours of the event. Despite being widely practiced, this approach is controversial as no definitive benefit has been demonstrated in the literature. However, widely accepted to be of critical importance for psychological wellbeing in the immediate aftermath of an emotionally traumatising incident is a ‘defusion’ process [4, 5, 6].

‘Defusion’ is a team get-together where thoughts and feelings are shared in confidence. When threat appraisals drench our brains in cortisol and distort our perceptions, defusion allows for piecing together the chronology and specifics of the event through organic, informal discussion with team-mates. It is an opportunity for emotional support, having a collective laugh/cry at the absurdity of the job, and an accurate information gathering exercise in a safe environment. The team pull together in the aftermath, are honest about their emotional frailties, and find strength in each other. It lacks the rigidity and intrusion of an uninvited formal debrief led by an ‘outsider’.

Pain shared = pain divided

Joy shared = joy multiplied [7]

In the hospital setting, it can be as simple as insisting on a chat in the coffee room after a big resus, or a quick get-together after work. It might seem minor, but unnecessary guilt, anger, confusion and other damaging emotions can be thwarted by this process. However informal and insignificant it might appear on the surface, it is of fundamental importance, and must be sought out, however logistically difficult.

In more extreme environments, such as combat or the prehospital setting, sitting down to defuse should also be used as an opportunity to regain a feeling of physical safety, get warm, hydrate and refuel (eat something).

Self-compassion via defusion is a critical strategy for building mental toughness. Taking care of yourself and your team after an acute insult preserves commitment to the job, and prevents lasting psychological scars that will render you less able to cope emotionally with the inevitable acute stress that lies in wait.

Summary

Use mistakes as signposts for self-advancement as opposed to sources of embarrassment. Own your failures instead of hiding them, and use them to guide your ‘practice’ phase.

Always remember to ‘defuse’ with your team after emotionally challenging cases/incidents. Share the pain, and multiply the joy. Never underestimate the therapeutic value, and heavy dose of perspective, that humour offers.

‘My Mental Toughness Manifesto’ Roundup

You are mentally tough if able to state the following (Part 1):

“I am 100% committed”

“I feel challenged”

To build and maintain mental toughness, I propose seven strategies over three phases of the game:

‘Practice’ (Part 2)

  • Immersion
  • Deliberate Practice
  • Visualisation

‘Perform’ (Part 3)

  • Tactical Breathing
  • Cognitive Reframing

‘Process’ (Part 4)

  • ‘Black Box Thinking’
  • Self-compassion

Own your performance.

Robert Lloyd
@PonderingEM

References

  1. Black Box Thinking. Matthew Syed.
  2. 2017 Royal Society of Medicine Easter Lecture: Creating a high performance revolution in healthcare. Matthew Syed.
  3. What do Emergency Medicine and Donald. J Trump have in common? Robert Lloyd, EMJ Blog.
  4. Mental health response to disasters and other critical incidents. BMJ Best Practice.
  5. Debriefing and Defusing. http://www.davellen.com/page21.htm
  6. Shoes, Sex and Secrets: Stress in EMS. Ashley Liebig. SMACC Chicago lecture.
  7. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.