Death in paediatrics

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It must be so difficult working in paediatrics, isn’t it? Seeing all these sick kids must be heartbreaking.

It’s been 11 years since I started working in paediatrics, and I get asked this question regularly by my non-medical friends.

And, to be honest, I’ve never found it that difficult. Sure, children die and it’s upsetting. But it doesn’t happen that often, and mostly they do get better. As a paediatric doctor, you learn to cope with the occasional, upsetting tragedy.

That was until I did my six months PICU.

The volume of major illness and death and the intensity of the work is emotionally and psychologically draining. Very bad things happen to very lovely families.

In my entire medical career, these six months have been the best learning experience of my life. The procedures, high stress situations, decision making and even dealing with difficult conversations will all make me a better doctor when I return to my home territory, PEM.

It’s taught me a lot about families – how couples cope with fear and loss and how their siblings make sense of what’s happening around them. Most of us will not have to face such a personal, confronting situations and, I hope, if it ever happens to my family I will be able to hold it together like so many of the families I’ve met.

PEM allows us the privilege of knowing families at their most vulnerable moment, but PICU takes that to a whole new level. We are literally sharing the worst moments of their lives with them. And we need to handle that well. Our training doesn’t prepare us for what to say or how to act, and I am by no means perfect. Each experience makes us stronger and better at our jobs and able to improve on the next experience and the next interaction.

PICU also teaches you about yourself – how do you react at times of extreme stress? Can you keep cool in a crisis? For most EM docs (and thankfully for me too) the answer is, and should be, yes.

But what happens afterwards, when it’s all over?

The recent Beyond Blue survey showed that doctors suffer from more mental health problems than the general population, yet we are less likely to seek medical advice.

During my time in PICU, after all the resus scenarios and difficult situations, I have never once been asked by a senior doctor  – are you ok? There has been no medical debrief and no discussion. In fact, in my whole career in medicine, I can’t remember ever being asked  ‘are you ok’?

It seems so basic and human, so why don’t we do it?

An excellent post by The Endocrine Witch highlighted this issue recently. We need to learn to look after each other more and specifically, senior staff need to take responsibility for debriefing and talking about the emotional impact  with their juniors.

About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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18 thoughts on “Death in paediatrics”

  1. Iris Thiele Isip Tan

    Thanks for referring to my blog post on endocrine-witch.net. I am currently mentoring third year IM residents and often remind them that their juniors need their support.

  2. It is so important to debrief. We recently had a tragic case in ED. Not only did we do an immediate session but one a few weeks later where ALL involved were invited (students, HCA’s, nurses, Dr’s etc) It was run by the hospital councelling service and was really helpful for the team. It was very much about looking after each other. We all cope differently with these situations, often heavily influenced by experiences in our own lives. I cope with most but show me a child the same age as my son and at the end of my shift I will curl up in bed beside him and hold him tight. Debrief is essential- not optional, and having friends and interests outside of work is also essential to allow us to all do what we do. If it doesn’t happen where you work ask why… what have you got to loose.

    1. You are lucky to have such great support at work. We all need to raise this in our own workplaces if this doesn’t happen. But debrief needs senior support so it can be difficult making the culture change.

  3. Great article. I rotated through a paeds ICU (Red Cross hospital in Cape Town) as part of my EM training, and although it was emotionally tough I was really impressed at how good the consultants were at acknowledging their own feelings and helping staff to deal with the stress. An important part of that was the fact that the senior consultants also showed emotion, got upset, and made an effort to debrief as a group on a regular basis, along with the social worker on the team. It made a big difference.

    1. Agreed, when the senior staff shows their humanity and vulnerability it helps the rest of the staff normalise their feelings.

  4. We could learn a lot from our psychiatric colleagues re team debrief. It’s pretty routine for them after a hard day. Needs senior leadership to make it work.

    1. I had no idea that psych did a more regular debrief. There’s no reason why they can do it in psych but we don’t in PEM/PICU.

      1. Yep: we quarantine an hour every fortnight for newbies and an hour a month for more experienced clinicians for guided reflective practice/clinical supervision.

        There are some VERY important principle to adhere to if you’re going to go down this path:
        – you get to choose your supervisor
        – your supervisor is not your line manager
        – you have a written agreement/contract re the supervision
        – the supervisee and supervisor should each access training about clinical supervision

        There’s more info and links re self care and clinical supervision via these blog posts:

        “That Was Bloody Stressful! What’s Next?” https://meta4RN.com/bloody

        “Nurturing the Nurturers” https://meta4RN.com/nurturers

  5. We do emotional labour. Not every day will be sad and heartbreaking, of course, but there will be events every month that touch us emotionally.

    Let’s not passively wait for each event to arise and THEN seek emotional support. Let’s be proactive.

    Let’s nurture the nurturers: https://meta4RN.com/nurturers

  6. Beautiful, straightforward, honest post — thank you. We should use our experience to help families cope, but keep something for ourselves — that inner part of us where compassion, common sense, and purpose keep us going. It’s here where we find ourselves searching for the hard balance between idealism and realism.

    Thank you for another great contribution.

  7. I don’t think you can underestimate the importance of a good debrief, I have been very lucky to attend fantastic ones. They make such a difference to the way I feel that night when I go home but also months and years down the line. Our debrief’s have always been led by the nurse in charge who it seems to come naturally to. I think, as a doctor, I have a lot to learn and hope to continue the good work!

  8. Thanks for the comments so far. It is alarming that nursing staff would have to arrange their own separate debrief because the doctors wouldn’t do it. Making a culture change of this sort is a long and difficult process. If we can’t even support junior (or senior medical staff), then medical students and auxiliary staff seem light years away. The nursing staff seem to be better at this. Maybe they need to take the lead?

  9. Good point Tessa, As a consultant of 25 years there is in fact no excuse for the lack of concern about the welfare of our junior staff,and a formal programme of assessing their welfare ,similar to the programme mandatory for psychiatry is long overdue,

  10. Great blog. As a community children’s nurse we care for the terminally ill at home. We are really good at caring for ourselves and the others in the team through and after the stressful times. A recent, sudden death of one of our patients has really tested the wider team and has highlighted that maybe doctors do not do the same for each other. The shutters have come up, debrief was more blame orientated, and there has been no TLC offered for them. The nursing staff involved held their own separate debrief and offered each other support. Why is there such a cultural difference between the professions?

  11. It’s a great point you raise, Tessa. I try and make a point of asking but sometimes it is the people on the periphery we also need to think about. It’s not just doctors and nurses affected by the bad resus outcome but the cleaners and the medical students who might not have the knowledge or understanding to process what is going on. It’s worthwhile asking and explaining and taking time with them too.

    But the basic message still holds, we need to look after each other.

  12. There’s a kind of macho culture in medicine (girls included). After an unsuccessful resus for example, it’s often a nurse who asks her medical colleague whether they’re okay – whether a cup of tea and a sit down is a good idea. The medical approach seems a bit too stiff upper lip in these circumstances, especially amongst middle grades. Consultants are better – but don’t forget that they need looking after too. Often the most senior get overlooked, despite carrying the most responsibility.