Author: Freyia Mahon-Daly / Editor: Charlotte Davies / Codes: / Published: 24/09/2024
This was originally published as part of the medical student iBook. Weve reproduced it here with some additions as we think its great, and as much as this is written from a medical student perspective, it could be a new FY2 or a new nurse – or an old hand.
Hes gone off again
One rainy Monday morning I was in the Emergency Department (ED) having just been shown around the department with the other medical student I was on placement with. The tour ended in the resus bay just as an elderly man was rushed in.
The paramedic began handing over by explaining how his patient had suffered a cardiac arrest at home and had regained spontaneous circulation following CPR and defibrillation; they were soon interrupted by one of the EM doctors saying Hes gone off again. A quick glance at the monitoring screen, quickly followed by one of the nurses beginning chest compressions, resolved any doubts that I had about what was meant by this. The team set to work following the algorithm that I was familiar with through simulation sessions but had never seen done on a real patient before. I joined the queue of people lining up to take a turn performing chest compressions and did so in a daze, feeling safe in the knowledge that the experienced team had the situation under control.
Following the third shock from the defibrillator, the patients pulse returned and the team stepped back for a much-needed pause. One of the nurses brought in the mans ashen-faced daughter. As the consultant began to gently update her, the monitoring beeped and no pulse could be felt. The team resumed CPR. After a further few unsuccessful attempts to restart the heart, the consultant voiced the thoughts of everyone present: Hes an elderly man with lots of co-morbidities, I think it is very unlikely that he will make any recovery, and if he does, I dont think he will have a decent quality of life. The team all nodded gravely, as the mans daughter leapt forward and held his face, sobbing. The other medical student and I turned to each other; both shaken up by the experience and full of unanswered questions about the scene we had just seen unfold, but the department was filling up and each member of the team was called away and disappeared into the crowd. There was no deliberate intention to ignore us, it was an unfortunate consequence of a busy department. The awful look of realisation on the patients daughters face as she realised the resuscitation attempts were futile unexpectedly appeared in my thoughts over the next few days.
I tried to discuss the patients death with a friend, only for my feelings to be dismissed because she assumed I saw similar scenes all day, every day as a medical student, and I therefore knew how to cope with it. It was suddenly very difficult to admit the truth; I had rarely encountered such an intense and emotive situation and I didnt know how to process it. Attending and partaking in a cardiac arrest call or witnessing a patient being stabilised in the ED after major trauma are rare events, and most medical students will only see a few during the course of their medical school career. Contrary to popular belief, the vast majority of your time as a medical student isnt spent helping to revive someone whose life is in immediate danger. Days on placements are spent learning to take histories and examine stable patients, and it can be difficult to know how you will react to a high stress situation.
A few days later, I was heading out of the department for lunch when I heard the red phone ring. My initial thought was to continue out of the department, pretend I hadnt heard the phone and avoid another upsetting and confusing experience, but then a doctor called my name and I felt I had no choice but to turn around and head back to the department. Another dramatic scene unfolded in resus; a woman had collapsed whilst shopping with her husband and had not received any CPR for approximately 8 minutes until the paramedics arrived on scene. Twenty minutes later I heard the familiar phrase; Are we all agreed? However, the consultants next comment to myself and the other student present put my previous experience into stark relief; Why dont you two put the kettle on? Ill join you after I have spoken to the family.
Half an hour later I was sat in the staff room clutching a cup of tea. The consultant knew that we had limited experience of high-stress situations, and wanted to give us the opportunity to ask questions and talk about how we felt. A few other members of the team from resus had joined us for the debrief and discussed aspects which had gone well, and things they would try to improve upon in the future.
As students, we were encouraged to share our thoughts and ask any questions, no matter how silly they might feel. The debrief was also an informal opportunity for team members to support each other through the difficult emotions that tragic situations can evoke. I was initially surprised that one of the nurses was crying. However, I realised that a composed and professional manner may not reflect the personal feelings of the staff involved. Another nurse commented that the presence of students served as a reminder that they should always take the time to debrief and look after the team, no matter how many patients are waiting to be seen, and that informal debriefs in the department should be considered important, regardless of whether students were present or not.
As a student in EM these two experiences, whilst clinically similar, couldnt have had a more different impact on my learning and feelings towards EM as a speciality. In the first instance, I was left with many questions about the clinical decisions that had been made and felt unable to ask for clarification. This impacted negatively on my learning, and caused me to become disengaged with the placement. After the second instance, I felt that my feelings and sympathy for the patients family had been acknowledged and validated, and I felt that I would be welcome to approach a member of the team for advice or support if I had any further thoughts or questions about the case. EDs often have formal debrief procedures in place, particularly for cases when there has been an adverse outcome. These offer an opportunity for the management of a situation to be evaluated with the benefit of hindsight. However, as medical school placements are so short, often students involved in an event will have rotated on and therefore lose out on formal debrief. Taking a few minutes to provide an opportunity to ask any questions and check-in with students has the potential to turn an overwhelming and possibly upsetting experience into a valuable learning opportunity. It can be difficult in a busy ED, but a gentle reminder may go a long way to encouraging a team to make time to debrief after a stressful situation. It may not always be possible immediately, but asking your mentor in the department if they could put aside some time to answer questions that you have about a situation may well result in an informal debriefing taking place, which has the potential to benefit the whole team, not least for any students present.
Editor Note: This honest blog from Freyia is a great reminder on the importance of debrief.
Debriefing after an event
There are lots of methods of debriefing – we often do a hot debrief immediately after the event, and a cold debrief some time after the event, when everyone has had a chance to collate their thoughts. The purpose of these is often multifactorial – to offload, and to improve things if theres a next time.
Our RCEMLearning TAKE STOCK blog covers some of these techniques.
I constantly refer to the St. Emlyns blog on debrief, as it has lots of useful tips.
I also think its worth sign-posting everyone to resources available for further support, along with highlighting what’s normal. Its easy for people to think its terrible theyre not sleeping its unhelpful, but normal. This leaflet from my trust is great:
