Processing traumatic events
A trainee’s perspective
As a new anaesthetic registrar, I clearly remember one of the
introductory sessions for all the new ST3s from the Trainee
Programme Director:
“At the end of virtually every emergency
protocol in the hospital it says to call the anaesthetist. That is now
you. This means that by the nature of the job you will be exposed
to some of the worst tragedies happening in the region. If you ever
need any support, then please come and talk to us because we
are here to help you.”
This felt both supportive and intimidating
in equal measure, but I naively assumed that I would probably be
okay.
I would describe myself as psychologically robust. I have no
history of mental health disorders, and am probably perceived
as someone who just gets on with things; never really struggling
at work despite the challenges of examination failure and having
small children alongside dual training.
I found myself replaying the scenarios again and again in my mind, and suddenly reliving each death without warning.
Halfway through my ST5 year, I became the senior registrar at the large tertiary Major Trauma Centre. There are equivalent positions in every region, but locally it is perceived as a very challenging
role. I was determined to perform well and be seen to cope.
It was a steep learning curve, but I quickly settled into the
responsibility. The work was enjoyable, and looking back it
was one of the most exciting and dynamic roles of my career,
especially the unpredictable nature of each day on-call.
Then, in fairly quick succession, I was involved in several sudden
deaths of previously well children. Initially I carried on, and though
feeling sad about the cases I did not feel overly damaged or that
my work was compromised. However, as time went on I found
myself feeling less sad when involved in traumatic events, and
then not really feeling anything at all.
My patience became very short, and I was increasingly irritable
and argumentative with my wife, children and colleagues. I found
myself replaying the scenarios again and again in my mind, and
suddenly reliving each death without warning. These processes
are termed rumination and intrusive thoughts – they are normal
responses to processing trauma.
In the days that followed I had flashbacks to this case, and at the point where I kept visualising my own son dead on the operating table having his organs harvested, I finally realised that I needed help.
I found myself drinking more, having previously only consumed
alcohol once or twice a week. Although never to excess, it
became normal for me to have one to two alcoholic drinks
every night after getting home. My sleep, already disrupted by
having two small children, became erratic, leaving me tired all
the time yet struggling to rest; attributing this to job stress, I was
determined to carry on and cope.
I was then involved in a paediatric organ donation in an infant
of a similar age to my son. Sub-consciously knowing that I was
struggling, I felt relieved when my fellow registrar offered to
do the case. Unfortunately, the child became unstable intraoperatively
and I was called to the operating theatre to help. The
situation was very tense, and the psychological burden of the case
was very difficult for the whole team.
In the days that followed I had flashbacks to this case, and at the
point where I kept visualising my own son dead on the operating
table having his organs harvested, I finally realised that I needed
help.
Fortuitously one of my friends is a clinical psychologist, and
after encouragement from my wife I asked Sam if we could
meet to see if he could help me. He was brilliant. After quickly
establishing that avoiding traumatic events was unfortunately not
an option with my chosen profession, he helped me understand
the psychological responses to trauma that I was experiencing,
and offered me tools going forward to help process and reflect
traumatic events.
One of the most helpful of these was the ‘Control, Influence,
Accept’ model, which I have used personally to help me during
the recent pandemic, and has also been helpful for some of the
other intensive care staff with whom I have shared it.
Figure 1. Control-Influence-Accept diagram
A psychologist’s perspective
Psychological responses to trauma include 1) re-experiencing
through flashbacks, nightmares and involuntary thoughts and
memories. 2) inadvertent avoidance of related stimuli, including
unintentional strategies to keep busy or distracted with the
aim of preventing unwanted thoughts (e.g. drinking alcohol),
sometimes resulting in emotional numbness. 3) increased
physical and emotional arousal, including sleep difficulties and
irritability.
Following a traumatic event, many people will experience these
types of symptoms; most will return to normal functioning within
3-6 months, but 12% experience post-traumatic stress disorder
longer-term [1]. It is almost never discussed that a similar
proportion of people will experience post-traumatic growth,
becoming more resilient and better adjusted, as a result of
learning from the trauma [2], and I saw the meetings with Joel as
an opportunity for the latter.
Firstly, we aimed to acknowledge that there were many
emotionally difficult aspects to Joel’s chosen line of work that
were unchangeable. It was important to avoid wishing his
profession could be easier in areas where it could not. It would
also have placed our time and energy in a place where we could
make no difference, and indeed might have increased a sense
of helplessness. Making space for this kind of acceptance meant
making room for the hard experiences that cannot be avoided –
about as challenging a task as there can be.
We also aimed to establish a clear articulation of what really
mattered to Joel about his work and the direction he wanted to
go with his life. Conversations about these issues are not typical
in everyday life and can feel grandiose, but having a strong
sense of how to fit our actions with personal values makes
it easier to bear the difficulties inevitably faced when we do
what matters. This finding has been replicated in various work
settings and is seen clinically, for example in chronic pain, where
increases in values-based action leads to reduced depression,
anxiety and disability [3, 4].
The Control-Influence-Accept exercise illustrates the main aims
of our meetings. Using three concentric circles (Figure 1), we
categorised key concerns into: those that were directly under
Joel’s control; those that he could influence but not control;
and those that were out of his control. Importantly, we placed
emotions within the influence circle. We cannot directly control
emotions, but we can influence them through our consequent
responses.
Lastly, we agreed that moving towards acceptance
was the wisest action for concerns that were out of Joel’s control.
Acceptance can have connotations of passivity or not caring,
but it is a very active and challenging staged process where
one is saying “My energy is not best spent on this, because I
have no influence on it”; to be swiftly followed by the question
“So where is my energy best spent to serve what matters most
to me?”
Using this exercise, I observed Joel taking and making
time to become aware of difficult thoughts and feelings that
surfaced when he faced challenging situations; deliberately
remind himself of the values he aimed to serve; and consider
what he could do to move towards them. The first move of
this type that I witnessed, and the most admirable in my view,
was acknowledging the problem in the first place and turning
towards help, so that Joel could live and work more aligned with
what he originally intended.
A trainee’s perspective - continued
Even just admitting to someone that I was struggling was really
helpful, and I began to feel better. I accepted that I wasn’t
going to be able to do the job perfectly, that my best was
good enough, and to be kind to myself. At the end of one of
our meetings I mentioned to my Educational Supervisor (an
intensivist and anaesthetist) that I was struggling and seeing a
psychologist. His reply was amazing. Without batting an eyelid,
he said “Good, I think we probably all should.” This response
was perfect for me as it normalised the whole situation.
The term resilience is overused, but I truly feel that it is probably an apt description of where I now find myself
After moving to another large teaching hospital, I almost
immediately experienced two further paediatric deaths; one a
hanging in a teenager, and the other an out-of-hospital arrest
in a baby. Although apprehensive about my response to these,
I was able to recognise them as potentially difficult events and
use the tools that Sam had given me to process them.
The
term resilience is overused, but I truly feel that it is probably an
apt description of where I now find myself, and psychological
resilience has been invaluable whilst acting-up during my
advanced year in intensive care medicine during the pandemic.
As a speciality we are stereotypically very good at looking
after our physical health; the archetypal anaesthetist in Lycra is
present in every hospital. We are increasingly recognising and
making steps towards improving our personal and corporate
mental health, and I hope that by sharing my experience more
of us may approach our mental wellbeing with equal voracity
to our physical health, particularly in the context of the fallout of
the COVID-19 pandemic.
If you are struggling with the fallout of traumatic events, please
speak to your Educational Supervisor, College Tutor or Trainee
Programme Director.
Help is also available from the Association
Joel Swindin
ST8 in Anaesthesia and Intensive Care medicine
East Midlands Deanery
Sam Malins
Honorary Assistant Professor of Clinical Psychology
Sherwood Forest Hospitals Foundation Trust
Twitter: @JSwindin
References
- Shalev AY, Gevonden M, Ratanatharathorn A, et al. Estimating the
risk of PTSD in recent trauma survivors: results of the International
Consortium to Predict PTSD (ICPP). World Psychiatry 2019; 18:
77-87.
- Calhoun LG, Tedeschi RG. Handbook of posttraumatic growth:
research and practice. Hove, UK: Psychology Press; 2014.
- McCracken LM, Vowles KE. Acceptance and commitment therapy
and mindfulness for chronic pain: model, process, and progress.
American Psychologist 2014; 69: 178-87.
- Vowles KE, McCracken LM. Acceptance and values-based action
in chronic pain: a study of treatment effectiveness and process.
Journal of Consulting and Clinical Psychology 2008; 76: 397-407.