This post, detailing my reflections on self care in clinical retrieval medicine, is the sixth in a series recording my reflections on the twelve months I spent working for Sydney HEMS in prehospital and retrieval medicine. The first post covers medical education – you can find it here. The second covers human factors – you can find it here. The third covers clinical lessons from retrieval medicine – you can find it here. The fourth covers more clinical lessons – you can find it here. The fifth post covers leadership lessons – you can find it here.
This post covers some life lessons that I learned or reinforced during my twelve months of prehospital and retrieval medicine. When I left the UK for Australia in January 2016 I had been awarded a Certificate of Completion of Training in Emergency Medicine (with Paediatric Emergency Medicine) and had spent 14 months working as a consultant in Manchester and in Oxford. Although I worked oncalls in both jobs, it was more usual not to be called in overnight than to be called in, and in both departments (most of) the rest of my clinical time took place between 0800-0000. It was a bit of a shock to return to working night shifts, then – and on calls where being called to the domestic airport to undertake a fixed wing mission (the shortest of which could be expected to take 6 hours) felt more common than not.
Interweave days on base when we had no missions tasked with crazy three-job days (with “Three Jobs” Gourlay) and self care becomes ever more important…
Food helps build morale (yours and everyone else’s)
Eating together is an ancient team building technique. Just before I started at Sydney HEMS, one of the departing docs gave me a silicone loaf mould she didn’t need any longer. I took this as a personal challenge to do a bit more baking (a wonderful mindfulness activity) and found my HEMS colleagues willing guinea pigs. Of course I didn’t stop with the loaf mould… My particular highlights from the year are chocolate Guinness loaf cake (I used white chocolate shavings on top), white chocolate and raspberry loaf cake (moist enough to work with gluten-free flour but you might need to test a few times) chocolate chip cookies (this recipe actually made 50 cookies I had to bake in batches of 10 – they were likened to cookies from Subway which I took as a compliment!) and peanut butter fudge (I made a batch with 50% peanut butter, 50% nutella for my gluten-intolerant friend – she approved).
CC24Needless to say my baking recipe book is in the next batch of stuff we are shipping out to Australia…
It doesn’t have to be unhealthy stuff (although this is often most popular) – I had a wonderful collaborative dinner on one night shift with some of the paramedics, contributing a course each… YUM.
If you have a chance to eat/pee/rest, do it!
In Emergency Medicine, in the NHS and probably in medicine in general, we are pretty bad at giving our bodies what they need, when they need it. In retrieval medicine, deciding you’ll just do this one more thing before you go for a bathroom break means that if the “batphone” rings, you have fifteen mins to departure (which is not long, because there’s stuff to do). I learned quickly to take the opportunity to eat/rest/pee when it arose – it might not arise again…
For this reason, my retrieval lunchtime starts at 11:30 (waiting til midday is too much like tempting fate).
There are no medals for going to work when you’re sick
Similarly, I’ve always had an NHS “you’re not sick enough to be off sick unless you’re febrile or vomiting” attitude, often realising the day after that I shouldn’t have been at work the day before. I was fortunate not to get really sick during my year at Sydney HEMS but I did get a head cold – not usually enough for me to call in sick. So in I went to work, only to be greeted with horror by my colleagues who promptly packed me off home to bed. Being able to equalise your ears is important in aeromedical work but they were also concerned I might pass on my virus and take out a few more members of staff – not an unreasonable concern.
I think there is a cultural attitude in the NHS around sickness that needs to change at all levels, led from the top. We need to stop making juniors feel guilty for calling in sick – it’s quite intimidating to call a consultant and tell them you’re not coming in. Nowadays I express concern for the person off sick, ask when their next shift is and ask for them to keep us posted – then I get on with my job. It’s not for us to judge how genuine sick days are among our colleagues just as we shouldn’t judge our patients’ experiences of illness. If we have genuine concerns about the longer term health of our juniors (and colleagues), there are avenues to address this properly (through foundation programme directors/training programme directors/occupational health/the deanery…).
JFDI 1: This is what you get paid for
Very occasionally in the Emergency Department we get shifts that start off “Q***tly” (the jury’s out on whether we can safely use the “Q” word – I’m taking no risks). When this happens we develop a sort of collective inertia. If there are no patients waiting to be seen, after a period of time no-one wants to see one, and when the next patient appears we all groan. This is amplified in retrieval medicine where I passed several 12h shifts without touching a single patient (at one point I went almost a solid month). We can be tempted to resent the work we do after long periods of inactivity but we must avoid this – from a human factors perspective it’s pretty risky. The most successful way I have of combatting this feeling is my mantra: “it’s what I get paid for”. I found this quickly refocused me on the task in hand. If this is something you find affects you after periods of inertia, congratulate yourself on your self-awareness, then try making it your mantra too.
JFDI 2: Shut up and smile
I admit that when I was the medical SHO oncall (many, many years ago), I was horrible. I was a nightmare to refer patients to; I would argue and criticise and generally be difficult. It was unacceptable and I’m still very sorry!
When the inertia has taken its grip and is broken by a call from the medical retrieval unit just before the end of your shift with a whopper of a job miles and miles away for a patient who doesn’t sound sick enough to need to be moved right now, that former attitude can start to simmer in the background. I am here to tell you to stop it! Yes, once again, this is what you get paid for and as such, it’s best to do what you’re told and smile. Be positive about the mission. The patient wants to be in this position even less than you do. If it’s really all that inappropriate as a job and there’s genuinely something to complain about, get the job done and complain about it afterwards. The service has quality control processes that can look at whether resources were allocated appropriately but remember; until you are there with the patient, you don’t have all the information. Put your ego aside and get on with it – you’ll be happier as a result (and so will your colleagues, as your positivity is contagious).
Do not underestimate the power of doughnuts at 1am to boost morale
If you do get tasked to a long job towards the end of a shift (my record was a 9hr job, starting at 17:00, 9h into a 24h shift in which I’d already done 6h “work”, finally returning to base at 02:00), recognise you’re all going to be flagging by the end. I would stash cereal bars in the pockets of my uniform and share them with my colleagues when needed – and on one night shift our crew shared a box of doughnuts on the helipad at the Canberra Hospital at 1am by the light of the supermoon. The time you find to eat opportunistically might be two minutes shovelling something very unhealthy into your mouth as you prepare to return to base, but you’ll all feel much better for having eaten something – especially if you are re-tasked on the way home.
Invest in your fitness
Being physically fit helps. It helps with the job, it helps with your mental health, it helps your sleep, it helps when you eat all kinds of odd stuff at odd times. There’s a culture of fitness at Sydney HEMS which helps a lot – I was never brave enough to get really sweaty on shift (in case I was called out for an urgent job) but I did use the last hour on base to walk on the treadmill and avoided rush hour traffic after night shifts by using that time for running instead.
I also gatecrashed a 26K walk from Otford to Bundeena through the Royal National Park with three of my paramedic colleagues who were testing out a new personal locator beacon on a day off – I can promise you the beer at the end was the best beer of my whole life. Five years ago, before I took up running, there’s no way I would have considered that walk and I’m so glad I did it.
It’s not easy to get started if you’re not an exercise person – so get in touch with us here at St Emlyn’s if you want advice and moral support towards making this life change (we have a variety of exercise interests and fitness levels!).
Time doing something totally different can be truly transformative
I wouldn’t have considered myself particularly burnt out when I left the UK but I am definitely more chilled as a clinician following my year of retrieval medicine. I feel more confident in critical care situations and am able to be more aware of how I communicate (and it’s not just me who thinks this – I have the benefit of feedback from my wonderful nursing colleague Sophie Payne who worked with me in Manchester and now in Sydney). The adage that “a change is as good as a rest” has some grounding in truth – of course there are stresses to working in a new environment (like feeling as though you have to prove yourself all over again) but the opportunity to reflect, start again and redefine yourself, and to experience something new can be very powerful.
You’re never too old to learn something new – stay humble. Even the most senior doctor can benefit from embracing lifelong learning – and recognising you don’t know everything (shout out to Justin Morgenstern for these words of wisdom) and don’t necessarily do everything in the “best” way is better for you, for your colleagues and for patients. I’ve picked up a whole load of tips and tricks, modified some established habits and considered some clinical practices more deeply. This doesn’t have to happen in a new environment – it’s an opportunity available to you every day, wherever you work, if you choose to adopt this mindset.
Get in the zone
If you can get yourself into the clinical “zone”, you can do all sorts of things you’d never believe of yourself. You may or may not know that I have a paralysing fear of spiders (the bigger the spider, the more I lose my ability to function even if the spider is harmless – it’s not logical, it’s a genuine phobia and yes, CBT is on my to-do list).
So I found myself on a hillside, intubating a child by the light of a head torch, a moth in my face and a spider crawling nearby – yet I was calm. Somehow, with a patient to look after, I found myself in the zone where I could block out unwanted stimuli (the spider) and get the job done (intubation).
I’m pretty proud of this (although less proud of the slight freak out I had when we finished dropping the patient off in the Emergency Department, where I shook myself thoroughly to make sure there was nothing crawling on me and asked the aircrewman to check my back). This kind of situational awareness, where we get to choose what affects us in a stressful situation, is something we should aspire to – somewhere we can practice at the higher levels of emergency care when most of the clinical stuff is second nature. If you’ve never thought about this before, start here with Mike Lauria’s post at EMCrit.org and pencil in a job at Sydney HEMS to hone these skills in yourself when you’re ready.
Sleep matters – do it often, do it well
Returning to day/night shiftwork was hard – particularly with 24h shifts on base at times. Although duty hours within that 24h period are tightly regulated in aeromedical work, our twice daily briefs included a frank discussion about crew fatigue with recognition that tiredness is a significant safety issue. Sleep should be one of your life priorities – for advice on getting the best from your rest, see this earlier post on sleep hygiene.
Up next: Life Lessons – the final instalment!
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