This is not normal

This is another letter to my previous self as a more junior trainee anaesthetist, hoping to provide some vague form of reassurance, and open up a dialogue for those who may find it helpful.

It is a very strange job that we do, and it's easy to forget that.

The things that we see - and what we do to people - are far from normal.

Most people may go their entire life and never see someone die. Maybe they'll see a family member's body at a funeral, or in very unfortunate circumstances they may even bear witness to a loved one's passing, but as a general rule the majority of the population are spared the harrowing and often horrific ordeal of witnessing the dying process occur in real time.

I saw three people die last week.

Three strangers' lives ended prematurely in front of me, they were distressed, alone and in pain and I witnessed the all too familiar moment when the light left their eyes as they lost output and we started compressions.

Each time we ran a great resuscitation - good communication, effective CPR and protocol followed to the letter - but as is the case with many arrests we didn't get sustained ROSC and had to call it after a time.

We debriefed, reassured one another that we ran a solid resuscitation attempt, that we gave them the best possible chance, that there wasn't anything else to be done, these things happen. I checked in on the student nurses and the new FY1 doctors, to ask if they were okay and if they had any questions or concerns about what had happened.

We then had to tell the horrified, shattered families that they had just lost their father, grandmother, son, brother. That we tried our absolute best. That there was nothing more that we could do to fix them.

• I watched a mother stroke the blood-stained hair of a son she never expected to outlive
• I watched a broken husband apologising to his wife of sixty-eight years, begging her to forgive him, to not leave him on his own
• I watched a weeping six year old girl climb into bed to hug her mother one last time, tears of agony dripping onto cold grey skin

Then it was straight back to labour ward to do an epidural for a woman gleefully anticipating the arrival of her first child.

You get no time to process.

A flashback

I'm not generally one to experience genuine flashbacks, but I'm certainly a pathalogical ruminator and tend to dwell heavily on events that were particularly emotional or traumatic, particularly if I wonder whether something could have been done that would have resulted in a better outcome - I'm sure many of you are the same.

I occasionally will get specific visual flashbacks to particular cases, and the one that's been haunting me recently is a man in his mid fifties that I saw in the Emergency Department as an ICU referral for exertional shortness of breath.

I arrived in a familiarly overstretched, understaffed resus room to find a clammy, sweaty and just sick looking man with panic in his eyes and a tremor in his voice. You could tell he was someone that wasn't used to being vulnerable, to not being in control. He pleaded with me,

"Please doc, just fix me"

His observations weren't appalling. He was on room air, had a peripheral sats trace of 93%, and a systolic of 132 mmHg on a regular heart rate of 115 bpm. An optimistic bag of plasmalyte dripped lazily into the pink cannula sprouting from his bruised ACF.

A, B, C and D all seemed to check out at first glance. I grabbed the ultrasound and slid an arterial line in to get a gas, and while the ABG machine churned away I put the echo probe to his chest.

I struggled for a while to find an adequate view, and moments later the ED charge nurse slid the gas results into my hand and I glanced down.

pH 7.17, Lactate = 8

I glanced back up to the screen and saw a pleasingly clear greyscale image of two ventricles, both of which were enormous, and neither of which were moving.

I looked at his face, at which point he shrieked,

"Oh f*** I'm going"

His pupils blew, eyes rolled back, face washed cement grey and his whole body writhed itself into extension, agonal gasps tearing themselves from frothing lips as neck veins ballooned with stagnant blood.

Pull the alarm. Start CPR. Igel in. Waters circuit... we go through the motions, we follow the protocol, we follow the protocol really well, working cleanly and effectively as a well-oiled machine, tick off the Hs and Ts, repeat the gas, the lactate climbs, the pH falls, and we finally stop.

It turned out the 'exertional dyspnoea' was actually 'unable to tie his own shoelaces' levels of severity, and he'd been refusing to seek help for months, so there wasn't ever much we were going to be able to do by the time he presented to us.

We debriefed, agreed we had run a slick arrest, that we'd given him the best chance of survival, that there was nothing more we could have done, nothing was missed. And we went about our shifts.

But I can still hear those four final words now as clearly as the day he died.

Take time to reflect

If you don't take at least a little time, once in a while, to reflect on the experiences you go through then it's easy to lose yourself in the relentless chaos of the job.

It struck me hard, just a few weeks ago, when I saw the absolute horror in the eyes of the medical student shadowing me. They'd never witnessed a full-blown resuscitation before.

• The thousand yard stare
• The brutal indifference of the thumping compression device
• The flailing limbs
• The agonal gasping
• The dehumanising reduction of a once complex and vibrant life to a blind algorithm of four Hs and four Ts

All brand new horrors searing their existence into his innocent mind.

I talked it through with him afterwards and asked if he wanted to take time to process and go get a drink, which he did. I said there was no pressure to come back, or if he just wanted company and to sit in the doctors office with us he'd be more than welcome.

He thanked me and wandered off.

It wasn't his response that struck me, it was my lack thereof. My comfort in such a distressing scenario was completely unnatural, and I hadn't realised until that point just how detached and calloused my mind had become to one of the most disturbing things that a human body can endure. Thinking back, I vividly remember the first arrest I witnessed, how it stung me with a sorrow and revulsion I hadn't encountered before, how I didn't feel right for several days after.

I don't feel that any more.

Does this sound familiar?

"All okay?"

"Yeah, just a messy arrest - should have had a red form - at least we stopped fairly quickly and got the family in. I'll just grab a drink and then I'll draw up for the abscess."

We're mammals, and sociable ones at that. So when we see a fellow human being lose their life, we feel a deep-rooted sense of loss and mourning, even if we don't consciously appreciate it. We might also feel some primitive sense of fear, because it makes instinctive sense that if one of our tribe has just died then our own life may be in danger too.

But we suppress this, because it gets in the way of effective and methodical resuscitation. And because we have work to do.

We dehumanise the patient by practising on torsos and overpriced SIM men that get us accustomed to the thousand yard stare and the appalling ABG numbers and the algorithm that rules over us. We do it because it's better for the patients that we can help, who do have a chance, and I'm not for one second suggesting that we shouldn't.

I'm just concerned that we don't think much about how this affects the compassionate, loving humans that went into their vocation to do good, to help, to heal. We certainly don't think very much about ourselves, often not until it's too late.

It's not that we're not affected, it's that we just adapt, and suppress the emotional, human response because it gets in the way of our training and effective resuscitation. But it's not gone - far from it - it just sits there beneath the surface, gnawing away at a bruised conscience until enough stress piles up that it rears its ugly head and we break down.

It feels like failure

We've all been to arrests where we knew from the outset that this wasn't going to work, that the patient was too frail, too unwell, that we would have seen a response to treatment by now. But we crack on nonetheless, because the relevant conversations hadn't yet been undertaken, or because the patient was unusually fit for their age, or because they're relatively young - albeit physiologically frail - and the thought of 'giving up' on a forty-two year old just doesn't sit right.

So it comes as no surprise to us, having intubated and run through the protocol a few times, that the team comes to a unanimous agreement that we should cease resuscitative efforts and allow nature to take its course. We usually feel relief that we can end this barbaric assault on human dignity and finally grant them some peace.

But deep down it still feels like failure.

When your job is to turn up and resuscitate people, it hurts to accept that you haven't managed to achieve what you set out to do, even if you knew going in that it probably would never happen.

Add that psychological burden of perceived failure onto the inherently traumatic experience of witnessing a human life end abruptly and painfully and you're looking at a recipe for a meltdown.

We have unique stress

Every specialty has its own unique brand of stress that plagues its practitioners, and anaesthesia is no different.

We have it easy in many ways:

• We don't have the uncertainty of the exhausted General Practitioner or ED doctor who has sent a patient home after only ten minutes of assessment, hoping that they'll be okay and nothing critical was missed
• We don't lose sleep at night wondering whether the patient we operated on in the morning will bleed or develop other serious complications
• We no longer bear the burden of the poor ward cover FY1, worrying whether anything has been missed for the 60+ patients they've been handed responsibility for over the next 13 hours
• We never have to trust everything will be okay when we leave at the end of an on-call shift, because we hand over to another anaesthetist who can fix things until we return

Instead we have very immediate stress.

We deal with high stakes, high acuity problems that need fixing right now or else, before moving straight onto the next one often with very little time to think in between.

Babies, adults, mothers, grandparents, children, fathers - whatever comes through the door with a 'right now' problem - we're expected to calmly and methodically piece back together as if it were simply a jigsaw puzzle sat peacefully on a dining room table, before the next bleep goes off or the next patient arrives in our anaesthetic room.

We also see everything.

• The medics come to the cardiac arrests
• The ED docs see the suicide attempts, the stabbings, the victims of drunk driving
• The orthopods come to the trauma calls
• The obstetricians come to the maternal haemorrhages
• The paediatricians come to the paediatric crash calls
• The cardiologists are there in PPCI with the repeatedly arresting MI patient
• The paramedics are there in the ambulance with the head injury patient you pray will make it to the neurosurgeons without coning
• The transplant surgeons are there when the heart comes out and the monitor falls to zero

But we see everything.

And there's no way that doesn't take an emotional toll, whether we realise it or not.

Even when it goes well and we succeed in our resuscitation, do we stop to think about what we just witnessed?

• A new mother nearly bled to death on the table - a husband was nearly a single dad to two young children and a newborn
• Someone's only child is now in a coma, headed in an ambulance to a PICU seventy miles from home
• A father's heart has restarted, but he may never regain consciousness

These are big things to see, to be part of, to live through.

Iatrogenic critical illness

The patient walks into the anaesthetic room, whereupon we remove their clothing, comfort and control, and after a few checks and a bit of polite chit-chat, we render them unconscious, unable to breathe, and dependent on life support.

If it wasn't directly iatrogenic we'd say this person was now critically unwell.

I just did that to a stranger, and now it's my job to ensure it's a temporary process.

Every other specialty is dealing with a problem.

• The surgeon is cutting to remove a tumour, or fix a hole
• The medic is prescribing toxic drugs to treat a disease
• The intensivist is intubating to revive broken lungs and buy the patient time

The anaesthetist is the only one taking a previously apparently well person and rendering them deliberately and critically unwell, even if it is only for a few hours.

No matter how routine the procedure, how relaxed the patient or how confident you feel as the anaesthetist, the reality is we feel that stress - that burden - every time we drift our patient off into oblivion and click on the ventilator.

I did this to them.

The take home message

Take it easy on yourself. Try not to expect too much.

You're allowed off days, grumpy days and sad days. Days when it's all too much, days when the thought of picking up another laryngoscope or needle feels like a mammoth effort.

That's normal.

Because what we do is not.

A useful video

Here at Anaestheasier we're always open for a chat and a debrief. If you're having troubles or worries, or have questions you want to ask us, please don't hesitate to get in touch - we're here to help.