It is your reaction that is the problem.

reaction2

 

I’ve been feeling a little uneasy about Scott Weingart’s opening talk from SMACC. It was an extraordinary talk, recorded live on stage for the EMCRIT podcast and it took quite a few people by surprise. He talked about meditation and negative contemplation….all good things, if they work for you, but still I am uneasy and here is why…

 

A few years ago I started a year-long job that was a bit of a distance from home. Far enough that I wasn’t going to be driving home after 13 hours at work only to come back again the next day. So I rented a hospital flat and was away from home for that year. On the first day, during induction, I was asked how I was going to cope being away from Mr Edge and our girls.

 

At the time, my answer was very clear. They are safe, they are well looked after, they are happy.
I was pretty chilled about it all because, and I can recall it so clearly, it was a time of horrendous fighting in Gaza and I had been watching online the devastation happening in the Middle East. The hashtag that stuck out for me was a chilling call for the International Criminal Court to deal with Israel. Now this is not a political blog post and I have nothing to say about that. Whatever the circumstances, as a human being, it was harrowing. In particular I saw a series of traumatic photographs of a broken man, walking a broken street with a plastic bag. He was picking up the pieces of his child, who had been torn apart by a bomb. The final image was shocking, it was a close-up of the contents of that bag. I think about that image often.

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Scott was getting at this… Imagining the worst case scenario will always set you free to make a leap, because it will make you realise the unlikeliness of that scenario coming true. It will give you the strength and courage to face the difficulties of your day. But do we really need to be so graphic? I think about that image a lot. Perhaps that is my own personal negative contemplation. My children are safe, they are well looked after, they are happy but it is a painful way to remind myself that this is so.

.

I play along with the rhetoric and philosophy of the Stoics. I keep Marcus Aurelius at arm’s reach in my school bag. In fact the Meditations of Marcus Aurelius was the book I took with me to Dublin (did I think I was going to get a chance to read it?). Like Seneca himself I could probably be considered slightly less than stoic at times…but that’s OK, I am after all a work in progress. For a start I do not join in deliberately with any Negative Contemplation. I don’t ever deliberately visualise my girls dead in my arms. I don’t feel the need to go that far. This is something that Scott brought up in his talk, he says he does this, deliberately, daily. Understandably he was met with stunned silence in the large auditorium. He went on to explain how this and meditation helps him get through the tough stuff and how you too could make a start yourself on the path to inner peace.

In this arena full of high achievers, we all want this to work for us too. Since SMACC I have heard a few people say that they are going to start meditating. They are rushing home to give it a go. But this is a bit of a word of warning…beware that it may not bring what you’re looking for and that’s OK.

I am not being a #meditationwanker and I am not having a go at Scott Weingart, VERY far from it. We are looking now to a future where our wellbeing is considered much more important and we can discuss mental health issues more openly. This can only be a good thing. In the past this would have been unconscionable. We need people like Scott, with the reach and influence he has, to say that it is OK to seek out help like this and to suggest tools that could help. I’m just saying, personally, I struggle with the meditation that he suggests and negative contemplation feels to me like the sort of self flagellation I accidentally achieve daily anyway. As long as I channel it to positive outcomes then that’s fine and it doesn’t necessarily have to be quite so traumatic.

 

So what CAN I do?

For me it is writing. I write a lot. Only a tiny portion ever reaches publication – the rest is all shit (you might argue the published bits are shit too). I am guilty more than anyone of trying something only a couple of times before moving on when I am not suddenly representing my country or winning awards but

My point?
Do what floats your boat.

I have friends and colleagues who meditate and boy do they do go on about it. I spent a lot of time punishing myself for not finding it helpful. I did this too when I couldn’t find what I was looking for in Tai Chi…I gave it a chance but after I while I went back to kickboxing because really I just needed to punch and kick people to help me feel peaceful.

It doesn’t matter if you can’t do what Scott Weingart says. Give it a try. If you try (and like anything, you need to give it time) and it doesn’t work for you, recognise that you didn’t fail and you don’t have commitment issues. It just wasn’t your thing. Stoics see it like this – it is not the problem that’s the problem, it is your reaction to the problem that is the problem. If this doesn’t work, don’t go beating yourself up…and it is not Scott Weingart’s fault either. So,

 

Meditate
Don’t meditate
Imagine the worst case scenario
or don’t.
Write
Watch Football
Read
Run
Study

It is in the deliberate and in the mindfulness that you find your thing.

Strike your own match against whatever is going to set you on fire.

Just make sure you strike it somewhere and remember it is unlikely to be your last match and that’s OK.

Facing personal biases and my next encounter with suicide.

topfloor

 

The Friday night school disco was always an awkward, fun, silly affair with smoke machines, rotating disco lights and the occasional shifty bottle of MD:20:20 smuggled past the headmaster. I had danced with Harry, the new boy. He was a bit different, I liked him. We had similar military family backgrounds and being fairly new to the school he was having trouble adjusting because of that. He was fun. We were 14. Nothing else mattered.

 

On Monday morning as we took our seats for the new week, with stories flying around about who got up to what, our head of year entered the classroom. He asked for our attention, he told us to sit and listen and things suddenly changed. Harry is dead, he said, there had been a terrible accident. He explained how he had been playing a trick on his little brother, pretending to hang himself with his belt, he had slipped and he couldn’t be saved. We were 14 years old.

 

It has been a while since I was 14 years old. The school has been pulled down, the tree we planted in Harry’s memory torn up to make way for new flats. A long time has past and yet I still can’t shake off this nagging feeling. I just can’t bring myself to believe that this is what really happened. You see, I think Harry killed himself and for whatever reason, we were not told the truth.

 

I have lost an alarming number of friends, acquaintances and colleagues to suicide in recent years. Shall we take a moment and get past the joke that maybe they just couldn’t stand to know me any more? Thanks…moving on…

There have been the two hangings, the two drug/whisky overdoses, the jumping in front of a train (two of those believe it or not!) and one that I think was suicide but I have never asked because, to be frank, I can’t bear to hear it confirmed. At work I have seen a few people who have taken there own lives. If you spend any time with the ambulance services it doesn’t take long before you see them. A hanging, a shot-gun to the head, an overdose.

The fact that every time it happens I really struggle to deal with it may be my biggest problem here. I haven’t ever been able to face it and so I haven’t been there for my friends. I haven’t been to funerals or memorials. I have avoided any discussions. I have been so angry about each occasion that I have refused to hear the details, I have never questioned what really happened. I don’t get upset, I don’t cry, I just get very very angry.

 

I mentioned this to a senior medical colleague recently and she seemed a bit shocked.  “You’re going to have to get your head around this” she said “to work in the emergency environment and not, you know, go nuts. Also, you can’t be seen to deal with this so badly”. She was pretty blunt. I hadn’t really thought about it like that. She might have a point. I really don’t know how my own thoughts or feelings of anger affect how I deal with family members, or how I am seen to react. I just hadn’t considered that before – how does my own almost irrational bias manifest? Do people see it in me or do I manage to hide it?  I don’t know the answer to that.

 

Doctors are more likely to kill themselves than people in other professions. We know this. It makes me angry. Female physicians are just as likely as male physicians to take thier own lives. It is only a matter of time before I have to confront this again. I hope I never have to but of course I will. I suppose we all have our own individual hang ups, our own personal biases that might make us react differently when they come through the hospital door. At least knowing what mine might be is a good start.

Right now I work on the top floor of the hospital. The emergency department is downstairs at ground level. I sometimes joke with colleagues that there’s no point in jumping out of the window here…I would only land in the ED and as we are the only ward to ever have a spare bed I would just end up back where I started. I don’t think they realise that the thought had on more than one occasion seriously crossed my mind. I have, on more than one occasion, driven home along the small winding country roads (that have a habit of claiming a lot of lives around here) at over 90mph, willing a truck or tractor to come the other way so I could just drive into it. I have been there. It was a bad time. Please don’t worry, I’m not there any more.

 

So why do I get so damn angry when others go and end their own lives? I don’t know, but I have a suspicion it may go back to Harry. It may go back to wanting to be told the truth. It may go back to knowing that, with recognition and support, any one of them might have been prevented.

At work one day I asked a friend what was wrong. I hadn’t seen him for a while. He looked tired and unhappy. He looked like crap. He shrugged and told me he had a cold and I accepted that. Why wouldn’t I? A few days later I learned he had taken his own life. I felt so so angry. I still do.

 

Tuesday: I appear to have hit a nerve or two with this post. I am replying to personal/direct messages but I am a bit poorly (D&V, will spare you more details).

Please do leave a comment below if you wish to.

 

Some more reading:

Hopkins Medicine: Why do young doctors commit suicide?

 

 

 

 

Speaking out: teams, juniors, leaders and what SmaccDUB taught me.

Shetland

Landing on the wrong runway has left with me a story to tell for life. It probably gets more animated each time I tell it over a drink or two…but for once, I’m not the guilty party…ish. I say “..ish” because I wasn’t flying the aeroplane, I was sitting there, holding on with white knuckles and a voice in my head saying “he’s the pilot, he knows what he’s doing”. I said nothing, so perhaps, I too am guilty as charged.

We had been out for a day trip. It had been a beautiful day making it slightly hazy which isn’t always the best for flying but for me it was a great view. We flew over our house and flew over my old school in the Worcestershire countryside. We waved at the tiny flecks of sheep in the fields and followed the main roads as they snaked along below us. I love flying and strangely, the bumpier the better. But all good things come to an end and we had to head home.

As we flew back to the airport I listened to control – he was telling us to land on runway 3-4. That’s definitely what I heard, he said it a few times. The problem was, as we came in to land, in an unsurprisingly windy and bumpy descent, I couldn’t see a 3 in front of me. There was, however, a giant, white number 2 painted on the runway. Something didn’t add up. This wasn’t the right runway but I wasn’t the pilot. I didn’t speak up. I just thought I must have it wrong. He knows what he’s doing after all.

It was a very bumpy ride but rather skilfully, he managed to land without incident. There were no other aircraft or obstacles to hit and we got away with it. That doesn’t mean the pilot wasn’t in trouble!

Last week I flew (as a passenger) back from SmaccDUB to Aberdeen. The lady in the seat next to me was not a happy flier. It was another bumpy one, the weather was rubbish (welcome to Scotland) – she hated it. She sat there hyperventilating and holding on to the armrest and then my arm. I was loving the turbulence but I didn’t think it was a good time to tell her my story. I did tell my colleagues who had been on the same flight as we stood waiting for our baggage – and their immediate (just back from SmaccDUB) critical care doctor’s style response – “Why the hell didn’t you speak up – have you learned nothing?”.

Well, that’s easy for them to say. I think flattening hierarchies is easier said than done. If you’re the boss, just allowing me to call you Rob at work isn’t suddenly going to make me question my judgement less or yours more. That’s a confidence issue that as a junior doctor, I’m not the only one who struggles with. There’s a lot of work to do to make the team understand your reasoning and play along.

The talks at SMACC were delivered by experienced and thoughtful bosses. There was a lot of discussion about leadership, team working and vulnerability in this line of work, about looking after each other and watching your choice of words. Will it help me develop leadership and understand team dynamics? Yes.
Will it shape the direction I go in? Probably.
Will I speak out when I need to? Well, I spent my week in Dublin surrounded by grown up doctors from my hospital. I probably didn’t contribute much because I didn’t feel I had much to contribute. I love this picture of us…and I am not stuck on the end but right in the middle. It will make life easier to have discussions when I am back at work, of course it will. They aren’t as scary as they look 😉

dubx

Would I speak up? Yes, now I would but it isn’t easy. Speaking up or calling someone out isn’t easy, whether or not they want you to “just call me James” when you’d rather say Mr Surgeon-Sir. Some of us just find it easier having rank slides. Dealing with team dynamics and leadership is not easy – wherever you fit along that flattened ladder. Some of us don’t find it easy to walk into a room of 2000 people and end up friends with everyone even if there is a free bar and Guinness is flowing. We are all different. I’m not necessarily quiet, I sometimes do say it how I see it. I sent a peace offering to someone the other day and have been met only by silence…you can’t have everything but you have to try.
These so called soft skills are anything but soft just as Liz Crowe (@lizcrowe2) told us in her fabulous talk about love in Dublin. For me, they are harder than learning renal physiology or anything anatomy related for exams. I don’t think I’m alone in that and that’s why we need conferences like SMACC. This week I have managed to keep up my life-long 100% pass rate for exams…but I think when it comes to the soft stuff, one way or another, I fail daily. SmaccDUB taught me that.

Small town excellence

Sometimes you have to turn things on their head and look at them in another way. I was made to recently by the boss…who had a slightly different (and of course far more experienced) point of view.

crackinthewall

I was grumbling to some colleagues about a subject that seems to be becoming my thing…the fact that where you live really shouldn’t determine if you live.

But it does.

Time and again I read and hear examples of this being so.

Scotland’s aeromedical service (@EMRScotland) only this evening pointed out on Twitter that London Air Ambulance (@LDNairamb) has 2 dedicated trauma teams on tonight, and Scotland has none. Northern Ireland has none. Dr John Hinds (@DocJohnHinds) regularly points out such inequalities and that trauma care in Northern Ireland is something of a lottery.

Where we live has consequences when things go wrong.

When my husband and I bought our beautiful cottage amongst the mountains we could not have been happier. For our youngest daughter, things were not so great. The day we moved in she became unwell. The bad nausea, vomiting, fever, photophobia, stiff-as-a-board type of unwell. I phoned the out of hours GP service and they sent an emergency ambulance. As Mr Edge went out into the dark to guide them to the house, I contemplated the longest time it would take to get us to hospital. I couldn’t help but question our decision to move so far from the big city.

But we chose to be rural and I know what you’re thinking. Scotland isn’t quite the outback…we aren’t relying on @ketaminh to fly us miles and miles across the land to definitive care, but none the less, where we live could have a huge part to play in whether  or not we live, should disaster strike. Distance to a local hospital might not be that great, but next stage distance to a teaching centre with ICU, neurosurgery, interventional radiology and dermatology (OK maybe not dermatology so much) being available on site must have an impact on the local population? Doesn’t it? Are there any studies?

Sure, we should strive to be centres of excellence in big cities, but we should be striving for even more than that if we are far away.

We have a brilliant District General Hospital. It is staffed by many talented,  enthusiastic and slightly eccentric but reliable and committed generalists. We are sometimes viewed by the specialists in the big city as being another ward of the Trust in which we all belong. Most of the time though we feel like the crazy Aunty that nobody wants to sit next to at a family wedding because she smells of mothballs.

Things are different here.

REBOA carried out on a London street to save the life of a young trauma victim is science fiction to us. If you suffer a traumatic cardiac arrest on the roads around here, you’ve had it. Sorry, did I use the word if? This is happening on local roads every single day just now. But I’m not just talking about the sexy trauma stuff. I’m talking about the other every day life changers: the tumours, the brain haemorrhages, the clots, the STEMIs and the time it could take to get you through the DGH system and on to definitive treatment.
Having a STEMI? The cath lab is quite far away, will thrombolysis do?
Emergency neurosurgery? Good luck with that.
Abdominal pain at night? Hi, I’m a new FY2 (seriously, that could be me you’re getting first).  I’m not really sure if DGH populations understand that? I didn’t before I came here.

The boss stepped in at that point…she stopped me in my tracks. She put it like this…

Of course it’s obvious that where we choose to live determines our chances….but our chances of what exactly?
Because of the geographical gap between us, it can make life harder to get people to the end result they might need but we do get people out the door and down the road when we need to. 
I believe that it is because we DON’T have all of their snazzy potential interventions and “things to try” at ANY cost, that we are far better at discussing and considering all the options, including death. Good old-fashioned end-of-life, death. We do palliation really bloody well. Sometimes, that’s what people really need and packing them off the big city might not be for the best. Providing a good death, with family nearby and consideration of comfort, dignity and DNACPR are as important when needed as ICU when it’s appropriate. I think we do that really well here.

She’s got a point.

The local population might not appreciate how different their care can be far from big teaching hospitals but maybe like me, they choose to live (and die) here anyway and for other reasons.

As for my daughter, after what seemed like a vey long trip, she jumped out of the ambulance, shone the pen-torch in her own eye and giggled on the long journey home with the packet of biscuits the nurses had given her. We didn’t sell up and move back to the big city. Not yet.

****

I posted this blog post about 24 hours ago. Since then I have learned the sad news that Dr John Hinds died today in a crash doing what he loved…risking his life to save others. Northern Ireland deserves the same care services as the rest of the UK.

Where you live shouldn’t determine if you live…but it does. RIP Dr Hinds.

 

 

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