Off Balance: An Emotional Footprint

It’s very pleasing to have a new contributor on this site. Toby Shipway is an anaesthetist with a special interest in prehospital and critical care medicine. He has worked on and off in the Top End of Australia with CareFlight undertaking all sorts of missions. 

After researching the topic of in-flight births, I found out about one particular retrieval involving a midwife from work.  On some downtime at the base she described a little about the case. A referral was communicated when she was already returning from a retrieval job with a patient onboard. She was to be re-tasked to a pre-term labouring mother of 22 weeks gestation an hour’s flight away from Darwin. An urgent transfer was requested because the patient was attending an isolated clinic with no midwife services or specialist paediatric facilities.

She was the only midwife available on shift but with a sick patient already on board. The mother gave birth just as the plane reached cruising altitude and the baby needed lengthy resuscitation with APGARs never exceeding 6. The mother, who had been given nifedipine for tocolyosis, delivered the placenta several minutes later and had a post partum haemorrhage of 800-1000mls, dropping her blood pressure to 45mmHg systolic.

Central Oz J Degenhardt
You can feel a long way from anywhere in the air over the NT.

The nurse was suddenly balancing the needs of two critical patients, with no support. She managed to start an urgent blood transfusion, draw up appropriate drugs and set up oxygen for the mother, put monitoring on the baby, perform intermittent bag valve mask support, address it’s dropping temperature and maintain communication to a beleaguered pilot. After landing they were met by doctors, nurses and paramedics to get mum and baby to hospital. Unfortunately the premature baby did not survive, passing away 2 hours post delivery. The mum responded well to ongoing treatment and was discharged several days later.

The nurse looks back on the case with regret and a feeling that events should have occurred differently, although all who reviewed the case praised her efforts. She remembers waking up that evening, her arms cradled as if still holding the baby. How do we move on from challenging cases? How do we deal with the emotional footprint left behind?

The Stuff They Forgot To Teach Us

The emotional impact of medicine on clinicians is a topic rarely addressed throughout medical careers. Medical and Nursing Schools devote little or no scheduled time to the topic with so much content vying for timetable space. However, as we step onto the wards it takes little time for complex patient situations, tricky professional relationships, or the erosion of personal lives to ambush the newly qualified. The difficult choices made by medical professionals and their profound effects on patients can cause considerable anxiety and self-doubt. We are, on the whole, naïve and under-prepared for these situations.

Pre-hospital medicine is a unique environment for patient care. The intimacies of one-on-one care, the patient’s fearful confrontation with their illness and the alien experience of the plane or helicopter emphasise a feeling of vulnerability. From a medical perspective, it is a contained environment, which means minimal external sources for advice and an enhanced feeling of personal responsibility.

The empathetic manner of clinicians is rightfully promoted as an integral part in the care of patients. ‘Bedside manner’ and ‘empathy’ became buzzwords in medical education with the aim to instill the patient’s perspective into the clinician. The ability to empathise with patients builds trust, empowers patient’s decision-making and leans away from clinical paternalism. Empathy also brings us emotionally closer to patients. The pain and suffering witnessed by medical professionals is an aspect of the job to which we become accustomed but exerts a significant emotional toll. This can play out in all manner of ways depending on the individual involved.

We do know more about this than we used to. Although rates of depression have not been found to be higher than the general population, rates of anxiety, substance abuse (in particular abuse of prescribed drugs), and suicide are higher than the general population. In particular female medical practitioners were found to have a 146% higher risk of suicide, with males at a 26% higher risk compared with the general population. Several barriers to seeking help have been identified including concerns about stigma, career development, impact on patients, confidentiality, embarrassment and professional integrity.

However, humans have an amazing capacity to adapt and the efforts of supportive colleagues, a non-blaming environment and the breaking down of the clinicians ‘unshakeable’ image are part of the solution to a complex issue.

 

The midwife recalls the case with sadness but from informal discussions at work and review of clinical notes it became evident that her handling of the case was outstanding. It really was the worst case scenario with a mixture of two critically unwell patients, a difficult environment, limited resources and a long time in isolation before clinical help could be sought. It was a credit to her and the people supporting her that she was back flying so quickly after.

 

Notes:

Those stats come from this report released by Beyond Blue:

Norris S, Elliott L, Tan J. The Mental Health of Doctors: A Systematic Literature Review