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I just wish we’d debriefed: The risk of not meeting after a critical incident

Feb 16, 2021

Written by Washout Curve

A PGY3 Critical Care SRMO working in an Australian hospital. A recently lapsed anaesthetic hopeful trying to find where he fits. Follow him on instagram @washoutcurve

As doctors we encounter a number of traumatic experiences. Debriefing is key not just for our mental health, but also for our educational development. 

I still vividly remember the first cardiac arrest I saw. As a third year medical student on my first clinical rotation in the Emergency Department I was thrust into the middle of an arrest as "an extra pair of hands" to do chest compressions.

I dutifully jumped on the chest and pumped through my two minute cycle before yielding to the next in line.

Stepping back from the patient, exhausted and gasping for breath, I was completely overwhelmed by what I saw — complete and utter chaos. 

People frantically running around the resus bay, lines and tubes everywhere, a sensory overload of beeps and buzzes, and in the middle of it all a limp and lifeless patient, barely recognisable in the eye of this storm. After thirty minutes of horror, the ED consultant called the resuscitation off. Everyone stepped back and gradually milled out of the resus bay.

I was stunned. I had no idea what I had witnessed. Why had we done what we had done? And why did we stop when we stopped? These questions would remain unanswered, as the ED consultant leading the resus wandered off to make some phone calls. My shock became confusion, then discomfort. The experience was a traumatic one, which I did not have the tools to process at the time.

I pushed it to the back of my mind. It was not until a few years later, when attending a cardiac arrest as an ED intern, that these feelings resurfaced. An almost identical scenario — out of hospital cardiac arrest, thirty minutes of resuscitation and then a decision to stop. 

But this time, the ED consultant’s response was a little different.  "Everyone take a moment - have some water or food, use the toilet. Meet on the flight deck in ten minutes for a debrief."

What is a debrief?

A debrief is a semi-structured dialogue following a critical incident. It aims to discuss the decisions made and the rationale behind them, as well as to encourage reflection on the performance of the team and identify areas of improvement.

Essentially – everyone sits down to discuss 3 basic questions:

  1. What happened?
  2. What did we do well and what can we improve on?
  3. How does everyone feel about what happened today?

Why is a debrief so important for juniors?

These three simple questions were my first experience in debriefing and I realised how effective the process can be as a teaching tool and a resilience building exercise. Despite the eerie similarities of these two cardiac arrests, my experience and emotional state afterwards could not have been more stark. The debrief allows us to process our experience, rationalise it and learn from it, rather than become overwhelmed by it.

Debriefing is a valuable teaching tool

The detailed play-by-play of the resuscitation allowed me to understand the big picture of what had happened – what caused the cardiac arrest, what we did and why, and ultimately why the decision was made to stop. The consultant invited questions and provided clarification and non-judgemental explanations. Where previously I had been left to dig through the rubble of the resus to find meaning, here it was given to me on a platter. While a cardiac arrest can be ripe with learning opportunities, the overwhelming chaos makes it hard to identify these lessons, let alone to understand the rationale behind them. While the experience itself teaches muscle memory, the debrief builds this into real understanding. 

The debrief allows for emotional honesty in a non-judgemental environment, where the team can unpack the complex emotions born out of a critical incident.

Talking is team building

Team self-reflection was also extremely cathartic. We acknowledged our strengths – effective CPR, following the resus algorithm and effective procedural skills, but we also addressed our shortcomings, task fixation and breakdowns in communication.

In a cardiac arrest, where the deck is stacked against us from the start, fixating on the outcome as a measure of our ability and skill can be detrimental to our sense of self-worth. While there are always areas for improvement, the debrief frames these in a positive manner – where hard work is acknowledged and opportunities to learn and grow are welcomed.

Fostering a culture of openness

Ultimately, the debrief serves as an acknowledgement of a shared trauma. Training and simulation cannot fully prepare us for the chaotic emotional storm of a critical incident like a cardiac arrest – and it can be difficult to process all of this. The debrief allows for emotional honesty in a non-judgemental environment, where the team can unpack the complex emotions born out of a critical incident.

As a fresh-faced intern, I was extremely overwhelmed and didn’t understand how I felt or should feel, but seeing senior colleagues discussing their own emotional state, and reassuring others who shared their thoughts validated my own feelings of stress and discomfort.

Debriefing early and often creates a precedent that we are a team, that our feelings are valid, and that sharing our thoughts and seeking support from colleagues is welcomed.

Tips for Junior Doctors About Debriefing

Buy in:

An effective debrief requires audience participation. While the team leader will cover most of the “what and why,” the value of the debrief lies in self-reflection, sharing and supporting one another. If you have questions, ask. If you have something to share – share it. If another team member needs support – offer it. 

Your feelings are valid:

I was quite emotional about my first cardiac arrest – you may or may not feel the same way about your first, second or third. You may find that each incident affects you deeply, or that none do. You may become more stoic over time. There may be one incident which, for reasons unknown, affects you profoundly. There is no one right way to feel and your authentic emotions are as valid as anyone else’s. In a debrief, you will be privy to the emotional states of your colleagues surrounding a shared experience. Support them and acknowledge their emotions, but do not feel guilty if you don’t feel the same way.

Debriefs aren’t just for cardiac arrests

While debriefs are synonymous with cardiac arrests, the framework can be applied to any incident – a near-miss, a medical error, the death of a patient (expected or unexpected) or even an episode of interpersonal conflict.

If you feel uncomfortable or confused about any situation, a debrief can be a useful framework to discuss this with a trusted senior or friend. In a supportive workplace, such discussions are acceptable, and encouraged. Make use of this resource whenever you need it.

Emulate those you admire

Every team leader has their own style of debrief. Inevitably you will one day be in a senior position and need to debrief with your junior colleagues. Learn from seniors you respect and take on board strategies you find helpful to develop your own style.

You can debrief with any colleague you trust

While debriefing is not a foreign concept to senior clinicians, some are better at it than others. You may find a debrief with your direct supervisor to be insufficient to your needs, or in the case of my first experience as a medical student - completely non existent. Mentorship is a core principle of the apprentice-style format of prevocational training. Identifying and regularly engaging with a mentor is a worthwhile experience for junior doctors, and a mentor can be an effective debriefing partner. A mentor does not need to be a consultant or senior registrar, and often a near-peer mentor (a resident or junior registrar who is closer to your level) can be more effective, as they share more recent lived experience with you, and can better empathise with the difficulties of being a junior doctor, having recently navigated them themselves.

Escalate your concerns

Debriefs can be a useful tool to weather the storm of traumatic experiences you may encounter as a doctor, but they are not a fix-all. All teaching hospitals have an established support system for junior doctors. If you feel a particular incident weighing on your psyche, escalating this to your JMO manager/DPET/whatever name your hospital gives this role is the next step.

Looking after your own health is paramount, and something often forgotten. Engage with a local GP who you can discuss your mental health with (they are also in a position to empathise with your experiences as an intern), see a psychologist or counsellor whom you trust, and work through the issue at your own pace.

Time off work, remediation for missed essential rostations and a structured return to work plan are all available options should you require them. While a debrief is a good start, it does not have to be the end of the road, and there are lifelines available to those who need them.

 

New interns and medical students will no doubt encounter their fair share of critical incidents in coming years. Take advantage of the debrief to learn from your experiences and emotionally process them. This framework is valuable for healthcare workers at any stage in their career and should be considered an expected part of a critical incident – one that you will become familiar with in coming years.

DRS4DRS promotes the health and wellbeing of doctors and medical students across Australia. For more information go to www.drs4drs.com.au

 

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