Parental Grief: Liz Crowe at DFTB18

Cite this article as:
Team DFTB. Parental Grief: Liz Crowe at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20208

Grief is complex and individual. It would be foolish to expect everyone to respond in the same way. Everyone is different. Just like there is no such thing as a normal sense of humour, there is also no such thing as normal grief.

Trauma, Teams and Tribes: Vic Brazil at DFTB18

Cite this article as:
Team DFTB. Trauma, Teams and Tribes: Vic Brazil at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20194

Victoria Brazil is a senior staff specialist at the Gold Coast University Hospital. She is a world renowned expert in the role of simulation in medical education.

Emerging infectious diseases : Mike Starr at DFTB18

Cite this article as:
Team DFTB. Emerging infectious diseases : Mike Starr at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20158

Mike Starr is not, despite what he tells you, the bassist for Alice in Chains. He is a general paediatrician and paediatric infectious diseases specialist at the Royal Children’s Hospital in Melbourne. He also happens to be a consultant in paediatric emergency medicine and plays a key role in the group that creates and collates the RCH clinical guidelines.

What is the evidence for high flow in bronchiolitis?

Cite this article as:
Tessa Davis. What is the evidence for high flow in bronchiolitis?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20191

Over recent years, the use of high flow nasal cannula in the treatment of bronchiolitis in infants has increased. Whilst it used to be mainly used in PICU, it is now widely used in EDs and on the wards. The recent PARIS trial examined whether delaying starting high flow in infants with bronchiolitis led to a worse outcome (it didn’t). See Alasdair Munro’s excellent analysis here.

But is high flow actually useful in these patients, and if so when? Should we be using it in our Emergency Departments at all?

The PREDICT research group published an updated systematic review this month in the Journal of Paediatrics and Child Health.

High flowing controversy: A return ticket to PARIS

Cite this article as:
Alasdair Munro. High flowing controversy: A return ticket to PARIS, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20129

Today we are all familiar with high flow nasal cannula (HFNC) as respiratory support. We see it in our emergency departments, on our wards and in the PICU. People rave about it, and people rant about it. People talk about it so much that there must be some high-quality evidence about it, right?

There certainly wasn’t until last year, when the much-anticipated Paediatric Acute Respiratory Intervention Study (PARIS) was published in the prestigious New England Journal of Medicine (if you haven’t read about the trial, most of this will make little to no sense to you. Have a quick read of the DFTB run down here, or read the article itself in full here).

This RCT of HFNC in bronchiolitis has stirred up strong opinions in some, and a few pretty convincing and controversial myths have arisen from it over the past year.

This take on HFNC and the PARIS trial may be a little controversial, so buckle your seatbelts (and please comment if you disagree).

 

Myth 1 – PARIS was a badly conducted study

If you hate HFNC and are looking for a take-down of the PARIS trial, I’m afraid this isn’t it. PARIS was a fantastically well-conducted trail, with an impressive write up. It was performed to the highest standards of clinical research and it has been clearly analysed. Most importantly, it finally provided the first attempt at high-quality evidence about an intervention which has already become a standard of care, despite having no evidence to support its use. The authors should be congratulated.

If PARIS was so well conducted, where have these myths come from? Almost all stem from a misunderstanding of myth number 2…

 

Myth 2 – Paris was a trial of HFNC vs standard oxygen therapy

This is a confusing myth, as the publication of the study states this is the case in the methods section and throughout the article. If this is what the authors say it is, how can this be untrue?

It can be argued that PARIS cannot be a trial of HFNC vs standard oxygen therapy, for two reasons:

  • In both groups, 100% of escalated children get HFNC at some point (you cannot compare HFNC vs something else if everyone gets HFNC).
  • The primary outcome for the two arms, despite being called the same thing, are actually different. For both arms the outcomes are called “escalation of care”, but for the HFNC group this means escalation to PICU, whereas for the standard O2 group this means escalation to…you’ve got it – HFNC.

You don’t have to be a research wizard to realise that having two different outcomes for your groups is a no-no. It means you cannot compare outcomes between the two groups, as you are not comparing like with like. The HFNC group has apples, and the standard O2 therapy group has oranges.

 

So, what is PARIS a trial of?

PARIS is a trial of a strategy of immediate HFNC for hypoxaemia in bronchiolitis, vs a strategy of rescue HFNC for hypoxaemia when standard oxygen therapy fails.

If we are not comparing the original primary outcomes, what should we compare?

In PARIS we should compare treatment escalation to PICU, as this is an equal outcome for both arms.

If we assess the study this way, we can see quite clearly that when comparing these two strategies, there is no difference in outcome of escalation to PICU (9% of standard therapy, 12% of HFNC, p=0.08). In fact, when we discount the original primary outcome definition, there is no difference in any other outcome between the two groups (except that the HFNC group were sicker when they got escalated).

The PARIS trial was an amazing piece of clinical research, but the write up has asked a strange question of the data and described the groups in a confusing way.

 

Myth 3 – PARIS demonstrated immediate HFNC is superior

Based on a misunderstanding of the above, plus a frequently stated statistic from the trial that:

The NNT of HFNC vs standard oxygen therapy to prevent one episode of escalation of care is 9

Some people have taken home the message that a strategy of immediate HFNC is superior to standard oxygen, as it prevents treatment failure. However, as we have already discussed, treatment escalation for the standard oxygen therapy group consists of being started on HFNC. All this means then, is using HFNC is superior for preventing you from later putting the patient on HFNC. Obviously, this makes no sense at all.

If we are discounting this mind-bending interpretation, and (as above) we see that an immediate strategy of HFNC changed no outcomes compared to a strategy of rescue HFNC, how do we decide which is better?

This is simple: when faced with two interventions which provide equivalent outcomes, you always pick the one which is cheapest and least invasive. Here, a strategy of standard oxygen therapy with rescue HFNC is the winner.

 

Myth 4 – PARIS tells us HFNC is effective in bronchiolitis

Sadly, PARIS cannot tell us anything about HFNC in and of itself, because we did not compare HFNC to no HFNC. Everyone got HFNC in the end, so there is no true control group. Although we can try and guess what would have happened in the standard oxygen therapy arm if there was no HFNC available, we can’t say this for sure as it didn’t happen.

Many people certainly believe that HFNC works and prevents PICU admission (which it may well do), but unfortunately PARIS cannot answer that question for us, and as yet no trial has done so.

What PARIS CAN tell us about HFNC is that it is safe. There were very few adverse events, of which it is unlikely any were related to HFNC.

 

If PARIS cannot tell us if HFNC is effective, how do we find out?

We want to design a study to tell us if HFNC is useful in bronchiolitis. First, we need to decide what we actually want HFNC to do. We are not expecting it to save lives, as children rarely die of bronchiolitis, and if they look like they might die then we have an effective intervention, which is to send them to PICU and intubate them. We also don’t expect HFNC to get children home any quicker, as it doesn’t treat the underlying disease process.

So, what do we want from HFNC? I would argue it is to keep children out of PICU, and on the ward. This is cheaper, nicer and less invasive. A win all around.

So how could we tell if HFNC keeps children out of PICU? We need a trial which compares rescue HFNC (which PARIS has demonstrated is preferable to immediate HFNC, as there’s no difference between the two), to standard care – basically normal treatment of bronchiolitis without using HFNC at all (hard to remember a time when this was the norm…). You then see if there is any difference between how many children go to PICU, or how long they stay there. Let’s put our dream study in a PICO:

P – Infants with bronchiolitis with hypoxaemia

I – Standard care + HFNC as treatment escalation

C – Standard care (no HFNC)

O – Admission to PICU/ PICU LOS

If the above looks strange to you, it’s worth remembering that not too long ago there was no HFNC, and there is certainly no way that the same number of children we currently put on HFNC all used to go to PICU instead.

 

Why hasn’t this trial happened?

If that’s the dream trial, where is it?

Unfortunately, because medical devices are not regulated in the same way as drugs, there is no requirement to prove their efficacy or added value prior to them being approved for any indication. HFNC made its way into every paediatric unit faster than a bronchiolitic baby can sneeze, and quickly became the standard of care without ever having any evidence it was effective. The horse has now left the stable, and there is no way of convincing people to run a trial in which half of the children do not get HFNC.

In the absence of any evidence, the world has now been split into a group of “HFNC believers” and “HFNC non-believers”, neither of which have any evidence that they are right (but many getting confused about the PARIS trial and sometimes misusing it to confirm their opinions).

 

Myth 5 – But I’ve SEEN HFNC work

Some people may read all this, and think,

“Yes, but who cares. I use HFNC and I have seen it help children and stop them go to PICU. We don’t need a trial, because we can SEE it works”.

Sadly, we have learnt from previous experience that even when people believe they have seen interventions work, sometimes when the evidence is finally produced it turns out we were wrong all along. This is particularly a problem for medical devices, due to the way they are regulated. Just look at the recent NEJM study for IVC filters to prevent pulmonary emboli, or the mind blowing ORBITA trial last year for coronary stenting for chronic angina. This is why randomised controlled trials are so vital. They have demonstrated millions of pounds have been wasted on ineffective procedures and devices in these scenarios, even when health professionals truly believed that they had seen them work. Time has proven again and again that we will often just see what we want to see.

 

Conclusion

  • PARIS was a fantastically well conducted trial
  • PARIS was NOT a trial of HFNC vs standard care. It was a trial of immediate HFNC vs rescue HFNC, and no differences between the two were demonstrated.
  • When two interventions provide the same outcome, you always pick the cheapest and least invasive option, which in this case is rescue
  • PARIS cannot answer questions about HFNC efficacy, but did demonstrate its safety
  • To demonstrate efficacy, we require a trial of rescue HFNC vs standard care (without HFNC), with an outcome of PICU admission/LOS
  • Current problems with device regulation mean they can be instituted without evidence of efficacy, and following widespread implementation it becomes very difficult to test their effects. We owe our patients better than that.

Additional reading

A recent meta-analysis of HFNC in bronchiolitis, including (and heavily weighted by) the PARIS trial, was recently published in the Journal of Paediatrics and Child Health. You can read our analysis here.

Anticoagulation in children : Fiona Newall at DFTB18

Cite this article as:
Team DFTB. Anticoagulation in children : Fiona Newall at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20144

Professor Fiona Newall is Director of Nursing Research at the Royal Children’s Hospital in Melbourne and has a special interest in anticoagulation in children. If you think that the only patients in a hospital that need anticoagulation are old people then you should watch this talk from DFTB18.

ConSEPT – the reveal: Stuart Dalziel at DFTB18

Cite this article as:
Team DFTB. ConSEPT – the reveal: Stuart Dalziel at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20055

Given that DFTB18 was held in Melbourne it was important to highlight the work of PREDICT (the Paediatric Research In Emergency Department International Collaborative)* This talk, by Stuart Dalziel, centred around ConSEPT and the management of convulsive status epilepticus.

Fluid assessment in sepsis: Elliot Long at DFTB18

Cite this article as:
Team DFTB. Fluid assessment in sepsis: Elliot Long at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19912

Given that DFTB18 was held in Melbourne it was important to highlight the work of PREDICT (the Paediatric Research In Emergency Department International Collaborative)* This talk, by Elliot Long, centred around his work on the role of fluids in the septic child.

The missing component of clinical practice

Cite this article as:
Damian Roland. The missing component of clinical practice, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19685

This is an extract of the talk I gave at #DFTB19 highlighting an important research ethos – the full talk will be released via the Don’t Forget the Bubbles at a later date.

The Doctor” is a painting by Luke Fildes and was first exhibited in 1891.

The Doctor exhibited 1891 Sir Luke Fildes 1843-1927 Presented by Sir Henry Tate 1894 https://www.tate.org.uk/art/work/N01522

The artist had lost his son Philip at the age of one and the scenes reflects the admiration that he had had for the doctor who had looked out for him. 

For some the painting may represent a stereotypical view of medicine in the past – the doctor rubbing his chin in a wise fashion, the child prostrate on a make-shift bed. And there is a parent figure in the background, watching on anxiously. 

This painting has had a revival recently despite being over 100 years old. It highlights the triad of care we all know exists in paediatrics – the child, the parents and carers, and ourselves.

This triad has received increased attention recently. The need for child centered care in respect of their engagement and involvement in their care. The need for positive communication with families; we remember the cases where parents haven’t acted as their child’s advocates but forget the vast majority of cases when they have. We so often let parents down when we should have been, not just listening to them, but honestly hearing what they were saying. And most recently the doctors themselves. An understanding of the importance of wellbeing and the shackles of rudeness. 

There is a fourth component, as well. One which perhaps will never get the attention it deserves because it isn’t a visceral part of our clinical care. It’s something we know exists but are quite willing to ignore. It’s something that perhaps has more impact on our practice than we would like to admit. It’s the variability in the actual care or treatment we provide or the fact that it might not be necessary at all.

When I became chair of PERUKI, Paediatric Emergency Research United Kingdom and Ireland, the international sibling of PREDICT and daughter of PERN I’d a personal vision that I would drive the organization forward in delivering ground-breaking new research highlighting novel interventions that would really make a difference to patients. What actually occurred is that I have realised that perhaps PERUKI has an even more important roll. One that does obviously include the need to develop, innovate and implement but one also that highlights where we could, and should do, better. It’s some examples of variation and the need for no treatment I would like to share. 

So this is an original selection of PERUKI members and those who helped us get PERUKI off the ground. I’d like a chance to pay particular tribute to Mark Lyttle at this point who has worked tirelessly at the outset to drive forward many early projects and is consistently named checked by our research partners for his ceaseless enthusiasm at collaborating and engaging. PERUKI took part in a prioritisation process published in 2015 with members putting forward their preferred research agendas and PERUKI publishing the top 20 via a Delphi process.

Number 4 on this list was: what is the best IV medication for Acute Asthma. PERUKI started on this work with essentially a two phase examination of the management of wheeze in March 2013. In the first phase a written questionnaire was undertaken. PERUKI sites responded as departments and 183 consultants responded individually on their wheeze management.

In study 99 (54.1%) use salbutamol as first-line intravenous therapy, 52(28.4%) magnesium sulfate and 27 (14.8%) aminophylline; 87 (47.5%) give these sequentially depending on response and 30 (16.4%) give them concurrently. Overall, 146 (79.8%) continue inhaled bronchodilators while on intravenous therapy.

When commencing on intravenous bronchodilators there were 10 different infusion rates with over 10-fold variation between the lowest and highest.

Everyone tends to have their little foibles about which treatment they prefer. And given the range of phenotypes and genotypes that exist in our wheezy cohort in can’t be the case that there is only going to be one best fit treatment for all patients. But a 10-fold difference probably pushes the bounds of flexibility.

What makes this more interesting is the second study. Also completed at the time (March 2013) was a prospective observational study. Data was screened from all patients presenting with wheeze and a detailed proforma completed for those who received intravenous therapies.Of 3238 children, 101 received intravenous therapies. Intravenous magnesium sulfate (MgSO4) was used in 67 (60.9%), salbutamol in 61 (55.5%) and aminophylline in 52 (47.3%) of cases. 

In 35 cases (31.8%), two drugs were used together, and in 18 cases (16.4%), all three drugs were administered.

More than half used salbutamol as the first-line intravenous agent, while fewer preferred magnesium sulfate or aminophylline, suggesting equipoise regarding which is most efficacious. To investigate this, participants were asked whether they would enrol patients to a randomised controlled trial allocating salbutamol, aminophylline or magnesium sulfate as the first-line intravenous agent, to which 148 (80.9%) responded positively. Asking clinicians who are regularly prescribing acute medications is vital for study design and subsequent implementation of study findings. With all due respect to respiratory paediatricians the question that they may be interested in, or want to explore, may well be completely out of keeping with the practice habits of emergency and acute paediatricians. PERUKI have welcomed increased engagement with our specialty colleagues in the last year and we hope we will reap the benefits of this. 

So a clear example of variation. I feel uncomfortable. Is there any reason to believe this variation has improved 6 years on? We have a challenge as the evidence base is not as strong as we would like. We look to Simon Craig and his work on developing asthma outcomes here – a PERN study I am very proud that PERUKI is part of. 

So what about where we think there is only a small amount of variation (a nationally agreed algorithm for example). DO we need to improve practice and CAN we improve practice? The EcLIPSE study was published a mere month ago and I am proud of the Don’t Forget the Bubbles team  for being part of the process of sharing this information widely. The Eclipse study compared levetiracetam and phenytoin in the treatment of status epilepticus. It was published on exactly the same day as the ConSEPT trial a similar study from our PREDICT friends. The EcLIPSE paper is available open access and there is a Don’t Forget the Bubbles summary. I also recommend the reviews by Justin Morgenstein and Casey Parker 

The primary outcome was time from randomisation to cessation of all visible signs of convulsive activity, defined as cessation of all continuous rhythmic clonic activity, as judged by the treating clinician.

Much debate has centred on what EcLIPSE and ConSEPT showed and at the heart of this is the difference between superiority and non-inferiority.

If these studies do nothing else it will to be to have spread the word about this construct. Because it is really important that people don’t glaze over or think because this terminology is used it’s someones else’s problem to analyse. I think this undue deference to academics probably perpetuates variation in care. I am not saying the theory is easy but neither is managing a sick neonate with congenital heart disease and we completely commit ourselves to doing that. 

Superiority trials aim to demonstrate that one intervention is better than other. The statistics, by convention, dictate that a difference between the interventions needs to be defined. In the case of EcLIPSE because phenytoin stopped status 60% of time and it was felt Levetiracetam may terminate seizures at a 75% rate the statistics calculated that 140 patients would be needed in each group. IF a difference exists this difference is likely to be a difference that is real and not by chance alone.

If they had wanted to show that levetiracetam was only 1% better then 1000s of patients would probably have been needed as if there was no difference by chance it would easily be possible that levetiracetam happened to be 1% better in that cohort of patients. 

A few interesting facts come out of EcLIPSE.

The first is that the while this wasn’t a perfect observational study – i.e not all patients presenting were recruited across a wide range of hospitals over 1400 patients were screened. This is a good cohort of children with seizures. About 10% of those who needed second line treatment for status were first presentations of afebrile convulsions and 5% were as a result of CNS infection.

Median time from randomisation to start of infusion was 11 min (IQR 8–15) for levetiracetam and 12 min (8–17) for phenytoin

But median time from randomisation to seizure cessation was 35 min (IQR 20 to not assessable) in the levetiracetam group and 45 min (IQR 24 to not assessable) in the phenytoin group.

These interventions take time! 

In EcLIPSE convulsive status epilepticus was terminated by levetiracetam in 106 (70%) participants, and by phenytoin in 86 (64%) participants. Therefore by the statistics LEVETIRACETAM is NOT better

Because the results are broadly the same it doesn’t mean they are equal – a non-inferiority study looks at two drugs and aims to calculate what is the minimum number of patients needed to be recruited into each intervention arm to demonstrate that one drug is not more than a certain % worse than another. By convention that number is normally 10%. The reason why 10% is important is that in EcLIPSE while it appears levetiracetam may have passed this test if the study had been designed as a non-inferiority in the ConSEPT study levetiracetam only terminated seizures (albeit as different end point) 50% of time; 10% worse than phenytoin. We don’t know yet what the meta-analysis may show us but this is planned.

A further suggestion is should we consider adding in levetiracetam with phenytoin; we could but that might delay some RSI intervention even further without overall benefit in seizure termination further. This is messy area where the complexity of clinical practice hints the required precision of research head on.

It might well be that you are happy for others to research novel drugs and techniques. You may well be content in supporting research through signposting or perhaps recruiting patients yourself. I would ask though that research itself is not scary. There is false divide between the ivory tower academic and jobbing clinician. Both these terms probably tribal and derogatory in their own way. We should all care about how effective our treatments are and where variability in practice is not in the patient’s interest. It is no more or less important than the three figures in Luke Fildes picture but perhaps it is less visible. 

Through PERUKI I’d like to champion this cause to make research feel more accessible. We are not doing research because we like to, we are doing it because we have to. 

Mirror Mirror

Cite this article as:
Andrew Tagg. Mirror Mirror, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19303

This blog post complements the talk I gave in the closing session of DFTB19. It has been recorded and will be released as FOAMed later in the year.

As part of my ongoing professional development I decided to volunteer for an experiment the Australasian College for Emergency Medicine were running. As a consultant it is really hard to get feedback on how you are doing, both clinically and professionally. You could ask your colleagues face-to-face but how honest an answer are you really going to get? So I enrolled in a pilot multi-source feedback program. Unlike traditional peer feedback and yearly assessments where you receive one-on-one feedback from the head of department, this was was something different.

I had to nominate 15 colleagues to complete an online survey about my professional behaviours. Anonymized to makes sure that things would not be seen as personal. I chose colleagues from all levels of my work life – from interns, registrars, peers, my immediate bosses and the Chief Medical Officer of the hospital. I chose doctors from specialities that I refer to on a regular basis and I chose non-clinical staff too. And in order to increase the actual worth of the project I included some people that I feel that I don’t get on with as well as I could (yes, they do exist!).

The findings were…interesting. There were the usual comments about drinking less coffee and learning to say no, both of which I fail at miserably on a regular basis. And then there was this one.

Now clearly this says more about the author than it does about me, but it did get me thinking about the impact we have in the workplace.

Emotional contagion

Human beings are social animals. We thrive in groups and, despite having had language for approximately 100,000 years, we rely on non-verbal communications to let members of our tribe know how we are feeling.

Charles Darwin, in his three-quel to The Origin of the Species, wrote that, despite their fleeting nature, our emotions are written large on our faces and this process is far beyond our control. But what is more fascinating is what happens when someone witnesses that unbidden display of emotions. Watch someone smile, genuinely smile, a mirror neurons light up in your brain. In a series of fMRI studies Rizzolatti et al. showed that the same are of the brain fires up when you witness an emotional display as if you had experienced it yourself. This reflexive, sub-thalamic response is emotional contagion.

Whilst our emotions influence our physiological state the reverse is also true. If I smile (more on that later) I feel happier. If I frown I feel more sad. And if I cannot frown – perhaps I have succumbed and finally got some botox to rid me of these troublesome wrinkles – then I will actually feel happier. Well, that is what some scientists have found.

Negative states

The problem is that negative states – fear, anger, boredom – are much more readily transmitted than positive ones – kindness, compassion, calm. Perhaps because they often come unbidden and out-of-control they are more likely to leak out before they can be contained.

This can cause major problems in the workplace as a doctor infects all those around them.

The work we do has a high level of emotional labour, moving from high intensity states such as dealing with life-affecting resuscitations to low intensity states of chronic constipation, without pause.

Some people are more susceptible to emotional contagion than others. Take a look at Docherty’s 15 part emotional contagion susceptibility scale and see where you might fall.

Doherty, R. W. (1997). The Emotional contagion scale: A measure of individual differences. Journal of Nonverbal Behavior, 21, pp. 131-154

And if you are the sort of person that finds themselves crying at the movies then you are not alone. I’ve left a little something for you on our YouTube channel for the next time you want to cut loose.

There are some highly infectious people that we can find in any department.

We’ve all met the MAVERICK – the hot shot doctor that thinks they know everything. They don’t need to follow the guidelines because they know better. They can send home the febrile 28 day old because they look fine to them. They can make the half-baked referrals because it’s the end of their shift and they have to get to their beach volleyball game. Besides the team will sort it out.

They make us fearful, nervous, a little afraid. Their arrogance spreads as they achieve more success, until…. They make a mistake. And they will.

So how can we help them? How can we protect ourselves and the department from their contagion? They need to be reminded, gently, that even Tom Cruise wears a safety harness. Guidelines are there for a reason. It’s okay not to agree with them but you have to be able to defend your actions. If you want to go your own way you need the evidence to back you up. Rather than ignore the MAVERICK and allow the worry to fester it’s important to head them off (whilst allowing them to save face). You set the tone!

What about the MOANER? You only have to go into the staff room of an y department in the hospital to spot one of these creatures. They are the ones drawing everyone into their spiral of doom as they complain about so-and-so from X (insert particular out-group here). Before long the rest of the group has been infected but their particular brand of emotional catharsis and everyone begins to moan.

It’s easier to not become one of them than it is to change their mind. This is the time for herd immunity. The more positive people there are in the room the better. Rather than joining in it is time to point out the dangers of stereotypes and labels. And should the opportunity to moan about your lot at work arise then it is time to take the higher ground. Remember, you set the tone!

And finally there is the MAGNET. Years of bad experience has led to a degree of learned helplessness. The more times they have been crushed by the chaos of the system the more they feel it is pointless to do something about it. At the mention of the Q word – the-word-that-should-not-be-named – they predict an apocalypse worse than any Private Frazer could dream up. Equipment will fail, stock will be missing or fall apart and there will be nobody around to help at the critical juncture – all because you said the word q.u.i.e.t.(shhhhh!)

So what can you do? It is time to role model the desired behaviour. You cannot control what is happening outside of your department but you can claw back a little control from the chaos within. At the beginning of every shift I check the key equipment that I might need to make sure it is working, I make sure that nothing is missing and I make sure roles have been allocated before the inevitable happens. I set the tone!

Manipulation?

All of this behaviour, including the examples I give in my talk, could be seen as manipulative, perhaps even a little sly? Teams that have a happier outlook, with members that embrace positive emotional contagion are safer and more efficient. Whereas when experimental psychologists have planted a MOANER as a confederate they found that teams became much less efficient.

Which sort of team would you rather work in?

Selected References

Doherty, R. W. (1997). The Emotional contagion scale: A measure of individual differences. Journal of Nonverbal Behavior, 21, pp. 131-154.

Vicarious Trauma : It’s ok to not be ok

Cite this article as:
Jasmine Antoine. Vicarious Trauma : It’s ok to not be ok, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19256

One afternoon my team broke the news to three different families that their children had a non survivable condition. That same week I was involved with a patient transitioning to a palliative pathway focused on comfort. I returned home to utter the words, “She is so sweet, I hope she dies soon.

For many of us, days like these, occur commonly.

Being a doctor is a privilege, an honour, a calling. Our jobs are stressful, diagnostically challenging, involve managing team members, and effectively communicating and engaging with different families whom have different needs. We are reliant on our knowledge and skills. What sets our job apart from other high stress environments is that any given day can involve death and dying. We see distressing conditions. Our day includes the uncommon, the unlucky and the unfortunate events of life. To the public these events occur few and far between, but for us it may be a daily occurrence -a relentless barrage of traumatic events, poor outcomes and sad stories.

The intensive care environment is difficult to navigate. The rates of burnout, mental health issues and self medication are high amongst our peers. 70% of junior doctors feel burnt out following a neonatal rotation. Strikingly, their (our) rates of suicide are twice that of the general population. Most of us have heard the words compassion fatigue. Some of us may even be familiar with vicarious trauma – the negative experience of working directly with traumatised populations. Compassion fatigue and vicarious trauma are on a spectrum. We initially may feel overwhelmed by our interaction but this can develop into symptoms of post traumatic stress.

At DFTB18, I spoke about some of the things we can do to reduce this happening to us, and the events above reinforced that message;

  • Seek the support of those around you.
  • Reflect with your supervisor.
  • Get together with your team to debrief.
  • Seek professional psychological support.
  • Foster a culture in your workplace that is supportive and open, whilst also taking time for yourself.
  • Make a regular appointment to see you GP.

And remember, it’s ok not to be ok

For more on this topic of the difficulties of dealing with death and burn out hit up DFTB at:

Burning out by Mark Garcia

A short story about death by Andy Tagg

Selected References

Boss RD, Geller G, Donohue PK. Conflicts in Learning to Care for Critically Ill Newborns: “It makes me question my own morals”, Bioethical Inquiry. 2015;12:437-448

Hauser N, Natalucci G, Ulrich H, Sabine K, Fauchere JC. Work related burden on physicians and nurses working in neonatal intensive care units: a survey, Journal of Neonatology and Clinical Pediatrics. 2015;2:2:0013.

Nimmo A, Huggard, P. A systematic review of the measurement of compassion fatigue, vicarious trauma and secondary traumatic stress in physicians. Australian Journal of Disaster and Trauma Studies. 2013;1:37-44.

Stress, burnout and vicarious trauma: looking after yourself. RACGP Webinar Series.