ED entomology - a tale from the resus room

May 2019

ACEM Winter Symposium Rotorua

https://acem.org.au/News/May-2019/ED-Entomology-A-tale-from-the-Resus-Room

A foreword (September 2021):

I have a difficult relationship with this piece of writing.

It began as a talk for the Resus on the Harbour conference in Sydney, September 2018. The organisers approached me and asked me to speak about clinician wellbeing. I suggested that I focus on civility and emotional intelligence in the workplace, which have been major contributors to my own wellbeing during my career and leadership journey in Emergency Medicine.

I needed a story to tell as a hook. I had told this story, which is a heavily deidentified real story from my early career, at the Sydney Trainee Wellbeing Day in January 2017. I discussed it with the organisers and we decided that this story, framed differently, would be a good fit for this talk too. It described a difficult day in the resuscitation room, which fitted with the conference theme, and it involved a challenging interaction with a retrieval team, who were among the intended audience for the conference. I knew it would be uncomfortable to tell and to hear, so I tried to lighten it with humour and to make sure the focus was on what to do well, rather than what went wrong.

I gave the talk and it went well. The feedback was really positive. I was subsequently asked to give the same talk at the ACEM Winter Symposium in Rotorua, May 2019. I polished it up, and again, the reception was largely positive. After the talk, I was asked to share it. The talk was not filmed, so the ACEM communications team and I converted my notes into a piece of writing, which was published on the ACEM website in May 2019.

The piece quickly went viral. The feedback from around the world, mostly via social media, was mixed - mostly positive but some negative, including criticism that this story included an unfair critique of the retrieval team. It was suggested that this writing represented ED vs retrieval tribalism. I felt ashamed, as this piece was never intended that way. In fact, the story had been deliberately chosen for the Resuscitation conference because both ED and retrieval clinicians were the intended audience. In real life, ED and retrieval teams work very closely together, doing difficult and rewarding work, and the vast majority of our interactions are positive. I was saddened by feedback that this piece of writing may have damaged some of my good relationships with colleagues working in retrieval services.

I was asked to publish an apology, so I added an afterword - which you can read after the story. I was also asked to take the piece down, so for many months I did. It felt wrong, however, to not own my work, especially something which was high-profile, so I publish it again here with this introduction. I have learned much from how this story was received and have changed the focus of my writing and speaking as a result. I have become aware of how a piece designed to be spoken to a live audience might land differently when transformed into words designed to be read.

I thank everyone who has contacted me for the feedback and advice you have provided to me and apologise for the hurt I have caused you.

I’m going to tell you a story.

Once upon a time, in the dim, dark recesses of time, at the dawn of the new millennium, a brave and idealistic physician trainee, in the throes of medical adolescence, made a big, bold decision.  It was time to ‘man-up’ and enter the Sydney real estate market.  She had a cunning plan – she would do rural locum shifts to gather a deposit.

To set the scene, let me describe the big city hospital where she usually worked.  It was the sort of place where a paper cut gets sent to the Integrated Hand Unit, where an Anaesthetics Fellow is stored in the bottom drawer of the difficult airway trolley, and where trauma means dealing with the psychological aftermath of your over-privileged upbringing – just imagine the emotional scars: your best friend’s parents bought her an Audi when she got her L plates, but you only got a Hyundai.

Compare that to the rural hospital where she did locum shifts.  There was one room, one doctor, two nurses, two cardiac monitors, and one ventilator – an Oxylog 1000. The next time the trainee encountered this antique machine was in a practice VAQ for her fellowship exam. It was the sort of place where they bring you lunch on a tray. Roast chicken and veggies, under a silver cloche – just like on Masterchef!  And lemon coconut slice for dessert, because they noticed that you really liked it last time. At this place, trauma (as I learnt on about my ninth shift there – because I am sure that you have worked out, by now, that the trainee is really me) means two cars hitting each other at high speed at the intersection between the motorway and the exit ramp from the McDonalds roadhouse, just out of town.

It was late afternoon when the ambos dropped off five patients from two cars. Three were unconscious, two were elderly, and one had brain visible through an open skull fracture. There was a woman in her thirties with an obviously dislocated shoulder, and she was wailing, screaming ‘I’ve killed my family’. There was a four year-old boy who seemed absolutely unscathed. The paramedics told us that they had requested a helicopter retrieval and that help would be arriving soon. Then they left.

We got to work. I intubated patient one. I felt mighty proud of myself, as this was my first time driving a tube without a consultant standing behind my right elbow. And I got the ancient ventilator up and running.  Meanwhile, one of the nurses did bag-mask ventilation on patient two. I sedated patient four, reduced her shoulder (completely breaking the separate proceduralist/sedationist rule), then gave her repeat doses of midazolam to keep her quiet and out of the way. I let patient five watch telly in the tea room and eat biscuits. He was perfectly happy. And, I did nothing for patient three. There were simply just not enough hands. Besides, his daughter, patient four, had reported that he had cancer. I also felt that grey matter on my gloves during his secondary survey was a poor prognostic sign.

Thirty minutes in, the promised helicopter had not arrived. We called in the local GP anaesthetist, who intubated patient two and ventilated her by hand. Sixty  minutes in, the helicopter had still not arrived. I called the networked trauma centre in the big city to ask for help but was told to call back when I had done x-rays to confirm the position of the endotracheal tubes.  Only problem was that this was the sort of place where you take the films yourself. Ninety  minutes in, the helicopter finally arrived.

There were three men in flying suits, and they perfectly demonstrated the ABCs of critical care:  accuse, blame, criticise.  There were no introductions.  None of them made eye contact.  They didn’t listen to my handover.  They took over the two intubated patients, and they fiddled with tubes and lines.  They criticised me for not intubating and ventilating patient three – who was basically dead.  They criticised me for sedating patient four without a clear clinical indication.  They criticised me for not doing a formal trauma survey on patient five.  About twenty minutes later, reinforcements arrived by road.  More men in jumpsuits.  They talked as if I wasn’t there.  They twiddled, they twaddled and they twoddled.  Then they packed up the patients and took off for the city.  All in a good day’s work, for them.  But boy, did I feel small.

We thanked the anaesthetist and sent him home.  The nurses and I wiped the blood from the floor and tidied up the resus bay.  We saw the rest of the patients on the list – most had waited for hours.  I found the locals pretty understanding compared to my usual big city waiting room crowd.  I remember removing pieces of sea urchin from a man’s foot that day.  My hands were shaking, and I was close to tears.  In this town, he just had me and some local anaesthetic, doing my best.  At my usual hospital he would have gone to theatre with a foot surgeon.  And, at the end of the worst shift of my career, I drove myself home.  All the way back to the big smoke – two and a half hours.  Listening to Triple J, because Smooth FM hadn’t been invented yet.  The next day, I called the trauma centre ICU and asked for an update.  I was told they couldn’t tell me anything because I was not a member of the treating team.

I called the locum agency and pulled out of all my shifts.  I decided to leave clinical medicine.  I enrolled in a Masters of Public Health, found a policy job, and mapped out a career in academia.

But – the Nurse Unit Manager rang me the following night, to check if I was okay – and I really wasn’t.  And she rang me the next day, and I still wasn’t okay – but I felt safe to talk about it with her.  And she rang me a week later, and told me what an excellent job I had done, and how the team really liked working with me, and how I had kept four people alive against the odds, and how lucky those people were that I had kept my head together in a difficult situation, and could I please come back and work there again soon.  And she eventually talked me into joining the emergency medicine training program, so I did.  And here I am today.

Don’t ever forget wellbeing.  As you’ve probably worked out, this talk is about my approach to wellbeing.  It’s all the rage, these days, to include a wellbeing session in a critical care conference, and it’s tempting to be cynical given growing emergency department workloads and pressures, but I’m glad that we are finally talking about it. 

The aim of this talk is very simple.  To make you stop, and think, about some really easy things you can do to improve wellbeing and prevent burn-out.  Because resus, critical care and emergency medicine are difficult – for all of us.

Emotionally-engaged leadership is honestly the easiest thing we can do to improve wellbeing.  Think about it.  It doesn’t require a committee, a budget, or an implementation plan.  Although I do feel I need to insert a quick disclaimer here – as the owner of disproportionately long legs, and a psyche that bubbles like a Rotorua mud-pool, I’m unspeakably bad at yoga and mindfulness.

Acknowledge emotion and the impacts of emotion.  It’s alright to feel stuff.  Project and channel positive emotion.  Motivate people through praise and encouragement.  Discourage criticism and judgement.  Reflect on the good things.  Say ‘please’ and ‘thank-you’.  Allow yourself to show emotion and be vulnerable – be a real human being.  Respect the emotions of others.  They don’t have to feel the same way you do.  That’s okay.  Make time, and space, for follow-up.  It’s easier than you think.  Just ask and listen.  Have a cup of tea together.  Pick up the phone.  Send an email or a text.  The rest usually falls into place.

I’m going to share some wisdom from my Year 11 English teacher – what an enormous contribution she made to my life!  ‘Your perceptions are your projections’.  This is the concept that you psychologically get back what you give out.  I always thought Mrs Gosbell was pretty clever for coming up with this, when my class was working through Pride and Prejudice, but when I googled it to write this talk, I discovered that she had borrowed heavily from the work of Carl Jung.  Your mindset is everything. At my work I’m known as an ‘anti-magnet’.  Objectively, on review of the M&Ms, I do see my fair share of difficult cases, but because the team believes my shifts will go well, they usually do. ‘Be a honey bee – Not a fly’.  This one came up when we were studying Lord of the Flies.  Think about it.  Bees seek out flowers and honey.  Flies are drawn to shit.  Make an active choice to be a honey bee.  Choose to be the sort of colleague that you would like to work with.  Choose to be part of creating a workplace culture that allows you and your colleagues to thrive.

We all know that there are good and bad emergency departments.  What makes a good department?  A culture of safety and trust.  It’s visceral.  You can feel it when you walk through the door.  What’s the secret?  Deep down, we all know this.  Good emergency departments have a sense of family.  Good emergency departments are all about love – love for your patients, love for your colleagues and love for yourself.  This is important because happy clinicians are safer and more effective.

Behave yourself.  I wish I didn’t need to say this, but sadly I really do.  Here are some etiquette pointers.  Assume that your colleagues are intelligent, well-educated and want to do a good job.  This should be the assumption on which your behaviour is founded at all times.  Even more so when your colleague is junior to you in the hierarchy.  Introduce yourself.  Make eye contact.  Hold conversations, don’t just talk at or over people – and this applies when interacting with your patients and your colleagues.  Respect the skill and care of others.  Don’t take over unless you are invited to, or unless you really, really, really have to.

We all work with critical care superheroes.  Vigilantes in scrubs, with special clinical powers.  They buzz around resus and do irritating stuff, like take over the tube just after the induction drugs are given, or insert intraosseous needles, just because they can, and ultrasound random body parts.  They ignore directions from the team leader.  I’ve been thinking about what drives these strange and magical creatures.  How do they know when their super powers are needed?  I used to think they were drawn to the bright light shining from under the laryngoscope blade – but the beam doesn’t make it all the way to the back rooms of fast-track.  So, I’m starting to think they’re attracted to the scent of a freshly opened vial of rocuronium.  Maybe their super-senses can sniff it out?  Regardless of what drives them, their behaviour is discourteous and disrespectful.  It undermines the confidence and authority of their colleagues.  They should probably just buzz off!

I’ve got another story.  We’ve all turned to a colleague after a resus and said ‘Gosh!  That was pretty tough.’  Then the colleague says ‘You think that was hard?  Let me tell you about the time that I did a resuscitative C-section, with nothing but a rusty screwdriver and a banana peel, while dangling upside down, with crocodiles nipping at my testicles…’  Honestly, that sort of response makes no-one feel good.  The correct response is ‘Yes.  That was really tough.  Are you okay?’

Never invalidate the emotional responses of others.  Because the only knobs that are required in the emergency department are of the mechanical variety.

Thanks – and remember that civility saves lives.

* Names of patients and details of events have been changed for privacy reasons

An afterword from Dr Clare Skinner (May 2019)
I would like to acknowledge the hard work and care of my colleagues from the retrieval service, with whom the vast, vast majority of my interactions are professional and polite.  I apologise for the hurt that telling this story has caused. It is difficult to tell an authentic story of workplace incivility, and one to which other health professionals can relate, without inadvertently painting someone as ‘the bad guy’.  My point, in telling this story, was not to criticise the behaviour of the retrieval team, who, after many years of reflection on this very emotionally challenging shift, I have come to understand were also doing their very best in difficult circumstances.  Instead, it was to celebrate the emotional intelligence of the Nurse Unit Manager who reached out to provide support, and to encourage all health professionals to reflect on the damaging effects of tribalism, incivility and ignoring our emotional needs.  I believe that every health team needs to actively work on the way they interact with others – at times, we are all guilty of negative behaviour.  To me, the Emergency Department is a safe and comfortable space, but I acknowledge that it can feel unfamiliar, and sometimes hostile, to non-Emergency clinicians.  I need to be aware of this, and interact with colleagues from other teams with empathy and respect.  Healthcare is a team sport.  It is not about ‘us’ and ‘them’.  It is about ‘we’.