Our last episode was about Nick’s 4-stage approach to dealing with a stressful scene where patient loss is likely and how to deal with break the news to their family with minimal confusion or emotional breakdown.
This week, we talk about how to help others on the team to deal with tragic scenarios so that the families we deal with have a consistent experience across the board. In essence, how do you lead others to deal with death as professionally as you do?
We all spend countless hours learning about the clinical care side of our jobs, which is a good and necessary thing. However, that doesn’t excuse the almost total lack of support on this subject. Given that only 4% of cardiac arrest sufferers pull through, 96% of such cases create multiple patients. Losing a loved one is so painful that it easily spills over into physiological sickness.
If we take our oath as clinicians seriously we should be well prepared enough in dealing with bereavement that, at the very least, we do not add to the trauma the family goes through.
Further Reading:
Nick Brown’s paper in the Journal of Paramedic Practice – Pre-Hospital Resuscitation: What Shall We Tell the Family?
Eoin’s paper – Death Notification Delivery & Training Methods
Key Timestamps:
08:20 – Why no one’s got a mental “meta-programme” for death.
09:30 – How to avoid escalation in the first place, plus a story about why you need to know who is who and if anyone else is about to arrive.
11:06 – Eoin’s trick for making sure he never forgets crucial names.
12:30 – Lead with the right foot and slow down to speed up.
14:16 – Why encouraging family members to ask questions is helpful.
14:48 – Where should we draw the line with physical contact?
16:41 – How to deal with metaphysical and religious beliefs.
21:27 – Dealing with the stress of treating cardiac arrest patients.
24:20 – The 3-Day Rule. How to work through a job that sticks in your mind and won’t leave you alone.
29:00 – Using non-verbal communication to de-escalate our colleagues on-scene.
32:06 – How to comfort a family member who is berating themselves for “not having done enough”.
33:20 – Can inexperience be mitigated somewhat by memorising a few pre-loaded answers to common questions?
36:40 – When you need to blot out all distractions and focus only on technical skills, as in the case of a 2-month old who suffered a cardiac arrest.
39:10 – The challenge of having to be “two different people” as a paramedic.
41:55 – The key take-home points from Eoin’s, Rich’s, and Nick’s perspectives.
Transcript:
Eoin: [00:07] This podcast is presented by Eoin Walker and Rich McGirr and is a Medics.Academy podcast. The purpose of this podcast is to provide paramedics an easy to access set of resources and educational materials wherever they are. Feel free to take a look at the description in the footnotes in the podcast and sign up today to find out even more about what we do and just how much content we put out there for your education.
Eoin: [00:40] Hi guys. We’re back with another episode of the Pre-Hospital Care podcast. This is a continuation of what we’ve been talking about with family witness resuscitation and also breaking bad news, and just digging down into the minutiae of how we both deal with and mitigate some of the stressful circumstances we deal with, which actually is some of the most difficult communication a paramedic has to face on the scene. Rich is here with me.
Rich: [01:10] Afternoon, guys. Hello.
Eoin: [01:12] And Nick Brown is still here with us.
Nick: [01:15] It’s like I’ve never been away.
Eoin: [01:17] It’s like he’s never been away! It’s like he’s always been here.
Rich: [01:20] Trapped in the basement with us.
[Laughter]
Eoin: [01:23] So, Rich, I’ll hand it over to you.
Rich: [01:25] Yeah, hi Nick. Thanks for staying and talking with us. This is a fascinating topic and I think it’s just too much to cover in one podcast so thank you for staying and chatting.
Nick: [01:35] It’s at least a whole module, isn’t it?
Rich: [01:38] It’s a whole module, yeah. Earlier, you took us through your four-stage approach to how you deal with families in a resuscitation environment, which is brilliant. What I’d like to approach now is how we model this behaviour and how we then teach this to staff, either newly qualified or people who have never done it before. What do you think the best way is for when you’re not there to get staff up to that level who maybe don’t do this very often? How do we help them in this process to make sure that the families’ experience of this is consistently good?
Nick: [02:15] It’s almost the answer to the question, how do we get good at anything, and I might have touched on this last time, you’re trained really well, you have lots of experience, and then you have good governance as well. It needs to be introduced in educational programs, and that for the most part these days is higher ed. But also in local training centres. It’s very hard to impress upon someone on-scene the importance of this if it’s a wholly new concept. It’s interesting, I gave a chat to some students at Surrey, or Sussex, at the university a little while ago, and the paper that I wrote was on their module or semester reading. That was good to see. I guess, rightly so, the emphasis in terms of cardiac arrest is on the clinical care and many hours will be spent learning the anatomy, physiology, pathology, etiology, other -ologies, as well as honing psychomotor skills as well. But there probably needs to be some space for sterile, clinical, moulage scenarios and actually build in factors where you have people role-playing relatives. There’s a certain art to that. It only goes so far. We all know the limitations of moulages and running scenarios, but nevertheless to introduce concepts I think would be a good idea.
[03:55] I think to teach an approach, a modelled approach, would be a good thing but I’m not so much in favour of strictly applying that or feeling like you’ve got to strictly apply that to every single scenario. But certainly on-scene, a number of options. Sometimes I lead on breaking bad news. I do try to encourage other staff, particularly students, and frequently I’m asked, ‘Can I come along and see what you do?’ And I do try to broadly, briefly cover what we’re trying to do before we go and engage the family and then we either share that load or they do it and I am there to support. I’m actually in favour of, if there is capacity, in having two people approach the family, although I generally think only one person talking is a good idea, perhaps for obvious reasons. But certainly there is some sort of moral support there in numbers.
Rich: [05:04] Do you think, from an education point of view, we find this topic uncomfortable? We’ve all worked as educators. We do take part in higher education training and station-based training and we do facilitate that. Do you think there’s perhaps a bit of uncomfortableness, if that’s a word, around acknowledging as paramedics and professionals that we deal with death a lot more than perhaps we think we do, and therefore we shy away from teaching about it, or we don’t know how to teach it?
Nick: [05:39] Yeah. Going back to the lack of literature on the subject itself. Of what there is, it seems to indicate that supporting families during resuscitation is a good thing, there is benefit, and some of the health-practitioner concerns that we touched on with the last episode in terms of relatives confounding clinical care or risk of medical legal claims seems to be unfounded. So there’s not a lot out there initially to ground you in taking some teaching forward. But I think perhaps as well it’s just not seen as the, dare I say it, the sexy side of what we do. Paramedics really need to avoid the trap of- and I think we know this as advanced practitioners- that we are summed up by what we carry in our bag, by how much plastic we can shove into a human body, or drugs, or what diagnostics we carry. And, of course, when people approach us and say, ‘What do you do,’ that’s what they want to know about. But hopefully what we do is we say ‘critical thinking’ and ‘decision making’ and ‘having an awareness of human factors’, because we know that’s an imperative before we come onto- and certainly, in terms of cardiac arrest, let’s be honest, there’s very little evidence other than pushing an appropriate speed and depth on the chest and pressing a shock button. So I think it’s seen as-
Rich: [07:16] That’s a really good point, actually. And from my experience from family and relatives and things, in the aftermath of someone being unwell. Very seldom to they talk about how amazing someone was when they put a cannula into somebody. It is about how kind they were, how they came across. They were really nice. They were good. And that ‘good’, that medical confidence comes from absolutely no basis in what I saw medically going on. It comes from how they made me feel.
Eoin: [07:46] I think it’s about building rapport quite quickly as well. And how you build rapport, how you communicate with patients, and how you de-escalate in that scene. And so you’re right, it’s very much the non-technical aspect. I agree with what both of you are saying. It’s very much the on-scene part of the role and it’s not something you can showcase to people by opening up your bag, quite rightly as you said. It is the most vital part because it is what the relatives remember and it also mitigates a lot of stress. We talk about meta-programmes and how everyone’s got these subconscious programmes for brushing their teeth, putting their clothes on, washing every day, but no one really has got a meta-programme for death because they don’t run that programme every day. Therefore, what you say and how you say it will stick with them for the rest of their lives. It’s really prudent to acknowledge that. And little subconscious anchors that people drop, the music or the sounds or the smells or your tonality will bring them right back to that moment. It’s so key that we get it right. But Nick, that leads me on to, and Rich, that leads me onto a question I’ll pose to you both about de-escalation techniques. Have either of you got any pearls of wisdom about how to either de-escalate family members and also de-escalate staff members, to de-escalate other paramedics, because certainly part of my de-escalation in the past has had to be towards other colleagues that feel completely stressed out. But if either of you have got any-
Rich: [09:32] I’ve got one gem or pearl of wisdom I try to impart on people when I talk about this and that’s to try to avoid escalating in the first place. I’ll give you an example of an error I made that escalated a scene. I was unaware of what family members were on scene. I know of the patient’s wife and the patient’s mother-in-law. What I didn’t realise was there were young teenage children on-scene. When I came to deliver the message and to talk about what happened next- and I’d been in contact with both adults frequently. When I came downstairs to deliver the final message, I was met by four people when I was expecting two, and it threw me entirely and it meant my next steps weren’t what I expected and I lost control of that scene because then it escalated with all the aspects you were talking about earlier with the begging, the crying, the grabbing onto my leg and as soon as that happened, I had an emotional response it became really difficult for me to help de-escalate them. And so, one of the things I took away from that is when I do talk to relatives, ask who else is here and who else is coming because people can arrive very quickly on-scene and you can go away from a relative’s room they’re in and go back to the patient and come back and there are 20 or 30 people there who weren’t there originally. You made that point earlier about knowing who you’re talking to. And I think knowing who you’re talking to and who might be talking to a little bit is really helpful.
Eoin: [11:06] I write their name on my glove. I write the name of the person I’m talking to on the inside of my glove because I know how forgetful I can be. I’ll write the patient’s name on my glove and I’ll also write the name of the person that I’m talking to but when I’m referring to the patient, either in the past tense or the present tense I will write their name on my glove because the worst thing in the world is to forget the name of the patient and skirt around that. So to cognitively offload that- but yeah, I agree with you, to contextualise who you’re talking to and how many people you’ll be talking to. But go on, Nick, have you got any- ?
Nick: [11:50] I would reiterate that, actually. I do tend to think, as most people do, that I’m the worst at remembering names and you hear that said a lot but we are trying to remember names at the worst possible time to remember a name.
Rich: [12:05] We have the biggest stress load and names actually aren’t the thing that-
Nick: [12:08] Yeah, our bandwidth is so full and now we’ve got to remember someone’s name. And particularly, of course, when the name is challenging or- and often calling the name of the paramedic who’s just been speaking to me. Whilst we’re on names and top tips for de-escalation, certainly do use your name at least and connect with people as we’ve said, do say that you’re a paramedic, give your title because there’s power in that. You’re showing competence and taking charge. So often it’s hard to get things back on track once they’ve slipped so if you try to get things right from the start then there’s more chance that things will follow logically, which seems counter-intuitive at a cardiac arrest when time is imperative, but the slowing down to speed up, allowing yourself some moments to think before you move on to the next stage.
[13:20] In terms of dealing with family, be truthful, or at least don’t lie is really important. It’s almost better to say, “I don’t know that yet.” Of course, the question they always want to know is, “Why is this happening?” Some people- we talked about the different approaches: the stoic, the stunned, the animated, but there are very many times we’ve been asked, “How has this happened?” They’re already trying to rationalise it, and we don’t always know that. Sometimes it’s obvious but sometimes it’s not. One of the things is to reassure them that to some extent it doesn’t matter. What we’re doing isn’t necessarily hugely impacted by the “how” bit.
[14:16] Encourage questions. So, “Do you have any questions?” Again, often you don’t, but tomorrow, next week, next month, we had the opportunity. You’re conveying something of yourself when you’re asking somebody if they have a question they’d like to ask.
[14:40] Okay, a controversial one. Actually, two controversial ones. One perhaps not as controversial as the other.
Rich: [14:45] We like controversy, don’t we?
Nick: [14:48] Personally, I wouldn’t be too afraid of physical contact, of touching people. I had this one cardiac arrest that I attended some time ago where the gentleman was elderly. He was a black african male and that had some bearing in terms of the cultural response that I had afterwards. Talking about 20 family members turning up, Rich, well, there was about 40 by the time we declared the patient dead and very accepting of the decision. But I got hugged and embraced by every single one in quite a powerful way. Now, it’s worth thinking about. There will be some people listening who would think that’s their idea of hell. I certainly
Rich: [15:35] I’m not overly comfortable, I have to be honest, now.
Nick: [15:40] No. I went with it, of course. But sometimes, thinking more generally, a hand on the shoulder. Touch, I think, is probably most powerful for me (moving on to another podcast) when we’re with ABD patients and thinking about managing the environment before we start pulling out an antipsychotic or a benzome. An appropriate touch. We could spend a lot of time talking about what’s appropriate.
Rich: [16:11] There’s something deeply human about contact.
Nick: [16:14] It’s that contact thing, yeah. “My name’s Nick. I’m here to look after you.” Hand on the shoulder. And you can do that with relatives, I think. But you have to be a bit careful. Again, you weigh up lots of factors and the scene. I dare say I don’t usually make the first move.
Eoin: [16:35] I agree, yeah.
Rich: [16:38] You’ve got to gauge your audience correct with that, haven’t you?
Nick: [16:41] It terms of breaking bad news, my second potentially controversial top tip is don’t talk about God.
Rich: [16:52] First of all, I think that’s probably more controversial than the first topic, the first point, but yeah I think this is a really good point and something I was going to ask because often you’re approached, you come into contact with in-death situations, with people’s beliefs, obviously. Now, working in London, those beliefs could be one of a hundred different religions formed in different ways and different aspects.
Nick: [17:15] Let me give you this as a real story. I’m attending a cardiac arrest in a Muslim household. We come to the recognition of life extinct decision. One of the paramedics on-scene announces to the closest relative that the patient’s soul is in the arms of Jesus.
Rich: [17:43] Okay.
Nick: [17:46] As it happens, that wasn’t received as badly as it could have been. I don’t think there’s anywhere that I’m aware of in terms of paramedic guidance of addressing the metaphysical. I think we have to be focused on dealing with matter and that is, obviously, trying to resuscitate the patient successfully back to an animated form eventually or dealing with the body as it belonged to that person. Once you get into the realms of speculating what happened in the afterlife, that’s not always that helpful, and for some people, you’re assuming what’s comforting to someone. Is it comforting to think that this person is in a happy place or another place? Well, that also opens up the realm of, well, perhaps they haven’t gone to the happy place. Perhaps they’ve gone to the horrible place. And actually, it’s more comforting for me to think that when I die, that is it, you know? And there’s no judgement or being sent here or there and what that looks like.
Rich: [19:02] It’s up to the relatives to grieve and to mourn to think in their own way about what happens next. It’s perhaps even the height of arrogance of us to assume that what we believe is what they will believe.
Nick: [19:15] Yes. Now, that’s not stopped me from saying, in terms of ongoing support, particularly in a house where there’s an overt reference to an imam or priest or vicar- In fact, the example I gave you from the job in South London, in the last episode, I’m sticking my neck out but I’d say they were probably a more liberal/moderate muslim family and I spent a lot of time talking to the son after the job. The family wanted me to talk to him because he was blaming himself for not being able to bring his dad back as he saw it with chest compressions. And we spoke about support and help and indeed, we spoke about the support and help he could get from his religious community. But once you leap in there with your assumptions about the afterlife there is the potential to cause offense. I’ve got probably three stories that I haven’t got enough time to tell where, you know, that’s probably the most overt example in terms of what was said, but others where there was clear uncomfortability when healthcare practitioners on-scene made suggestions of where that person’s soul might be now.
Rich: [20:33] I wonder if, in that particular instance and also generally, when we do that and we impart our beliefs on what’s going on, that, in some escence is a way of that practitioner removing the stress of the situation from themselves. Finding comfort for themselves in what’s clearly an uncomfortable scene with a lot of emotion, which (it’s like I’ve done this before) brings me onto my next question, which is how do you mitigate the stress of the scenes, clearly without imparting your own beliefs on a patient, but what in- you’ve talked a lot about the weeks, the days, the months after for the relatives, which I think is fantastic, and that’s actually a perspective I’ve not thought of before, despite having known you and talked to you a lot about this subject, that’s something I’ve learned today, really, and that is to think in that way, which is great. But what about you, us, the profession, days, weeks, months later? How do we mitigate that? Or how do you?
Nick: [21:27] Sure. I think we- It’s interesting, isn’t it? Where does stress come from? It’s hard to pinpoint. We’ve all had a huge amount of experience dealing with cardiac arrest. I bet that we’ll be hard pushed to think of, well, how many cardiac arrests would you be able to readily recall. I might- five, probably, straight off. Whereas when we’re getting towards ten, I’d be struggling.
Rich: [21:55] It’s probably the worst ones that you- The ones where there is a salient point that you remember, they stick with you and the rest-
Nick: [20:03] One of the things I often hear is, “How do you cope with so many cardiac arrests and the stress involved with that?” Stress is an interesting thing. I was more stressed in a previous job where I had an operational, supervisory role, and organisational stress caused me far more sleepless nights. So it is interesting where it comes from. Mostly, it’s not the body on the floor, is it? It’s dealing with the going back to families. It’s their reaction and knowing the suffering that they’ll be going through in the days, weeks, and months. That’s where it comes from. I think there can be a lot of benefit in knowing that we have done our best. It’s worth, as I say, training hard, getting the experience we can, getting the governance and thinking about our actions in cardiac arrests and being mindful in all that we do so we can come away thinking we’ve done our best and if we haven’t, what lessons we’ve learned for next time. Let’s be honest, most of our hard-won lessons haven’t come from reading something and going, “Oh, I get that now. I’ll employ it every time.” It’s quite often from a mistake. Also, and I do try to remind staff on debriefs, we have to remember how exceptional and challenging this job is. To take staff that go from A-levels to university with a little mentoring in between and put them in these pre-hospital environments, where there is so many factors to juggle, so many stresses – dealing with family, dealing with other environmental factors, safety issues, coming up with working diagnoses, treating, conveying, discharging – it’s a tall order. When you think that we do, the average paramedic does not many, whatever number we’re saying, cardiac arrests per year, it’s a significant undertaking. In doing that, you give yourself a bit of a break in terms of putting all that pressure on you. You can perhaps alleviate it in that way. I did a job, only a few days ago, actually, with another advanced paramedic. During the debrief- it was a big job. It involved lots of staff. In the back of the ambulance one of the things she said was talking about the “3-Day Rule”. I don’t think I’d heard it articulated in that way before. Essentially, bottom line, I’m going to think about it tonight. I’m going to think about it tomorrow. It’ll probably be that it doesn’t dominate my thoughts on day 2 and on day 3 it will be starting to fade a bit and I’ll be getting on. Beyond that, you might think, if it’s still like it was on your drive home from your shift, perhaps you need to think about doing something about that. For the most time, that will be talking to our crewmates. I think what’s useful- and it’s difficult if you’re a relief member of staff and you don’t work with the same crewmate each day, but to have good, strong working relationships as foundation so that you can go to people who understand the job, understand the pressures and strains. When you’re telling the story, they’re there too, in their mind’s eye. I think that is where most people draw their support from, as opposed to rush off to the counselor after dealing with upset relatives.
[25:40] A good debrief is important, and it’s something that if you’re leading a cardiac arrest we need to be able to do. It can be challenging for people to speak their mind in the back of the ambulance after the job. Often I’ve collared someone separately to one side and asked them if they’re alright. And as I say, you have to be real about your emotions and not hide those away. To some extent, figure out what works for you. We’re all very keen to come up with some sort of formula that we can apply to everybody but what might work for your guys might not work for me.
Rich: [26:19] That’s a good point. As paramedics or as clinicians in any form you like the cure for things. But the cures for a lot of things aren’t simple and they’re person-specific. For me, with that 3-Day Rule, I tend to extend it to a week, for me personally. By the end of my run of shifts for a week if I’m still thinking of that patient in the same way I was before, if I’m still talking to colleagues about that call, questioning my treatment, my judgement, things like that, then maybe I need to talk a bit more on a non-clinical level about why. Or at least look to myself as to why I’m still talking about it from a clinical level. My growing as a person, (it’s got very serious now, hasn’t it?), and as a clinician is part of understanding my emotional response to things and understanding it’s there and understanding that it’s okay that it’s there. We are all human beings and that comes with emotions and it comes with an emotional response. That’s normal. Thinking that it isn’t normal is what leads us down the wrong path, and leads us to stress where there doesn’t need to be.
Eoin: [27:30] I agree with both you, really. It’s accepting yourself. It’s being kind to yourself. It’s also, like you say, externally processing, just what Nick was saying about externally processing it with your crewmate or externally processing it with, sometimes, your partner, and just talking it out. When I used to do the clinical support or even some of the stuff we do as advanced paramedics, when you’re listening to another paramedic on the phone, unfolding a case in front of you, it comes to its natural conclusion once they talk it out. The process of talking it out just unpacks it for you to talk about it a little bit more.
Nick: [28:09] Absolutely. You’re drawing on some good psychology there. It’s how we declutter our minds. We articulate them, our thoughts, and we end up with a narrative that makes sense. We’ve got to go up a lot of blind alleys and repeat ourselves and contradict ourselves, and that’s okay, in order to come up with something coherent. And that’s a lot of it. It’s making sense. A lot of the debrief, as I see it, is making sense of events because we struggle when we can’t make sense because that’s chaos and we don’t like chaos, generally. We have to walk the line between chaos and order. Talking things through helps facilitate that.
Eoin: [29:00] Absolutely. 100%. One of the things I do to de-escalate our colleagues on-scene sometimes is- because it’s all non-verbal isn’t it? You alluded to it earlier. You step on-scene and it’s almost what’s not said which you gather more information from. It’s the look on the paramedics’ faces when they’re handing over to you or when they’re dealing with the scene, it’s the look of the family, and it’s some of the tonality of the communication. Sometimes that’s far more telling than what’s being said. What I will do is purposefully slow my communication down. I will try to calm my tonality down because non-verbal communication is 55%, tonality is 35%, and the rest is-
Nick: [29:52] Who came up with those statistics?
[Laughter]
Eion: [29:54] What was it? 95% of the time, all statistics are-
Nick: [30:00] Yeah, we know it’s powerful.
Eion: [30:04] It’s really powerful. And then doing something that I think is being done more and more frequently now – I’d be interested to see if you guys see it – is sharing that mental model, and if it’s not been done, taking a little bit of a time out, the next 10 seconds to the next 10 minutes, to 10 for 10, to re-evaluate where we are as a team and reassure your colleagues on-scene that everything is being done and what that does is de-escalates, hopefully, in their minds, but what it also does is it frees my bandwidth up to see (a) what needs to be done straight away and (b) when can I get to the relative.
Nick: [30:44] And the relative waiting in the wings can see that. There is power in a well-run resuss. Not least because it’s what’s right for the patient and it brings order to the scene in the minds of the practitioners that you’re overseeing and, of course, the empowerment you give them to do that. But also from the relatives who might be witnessing. It’s comfort to them, if not in the time, in the days, weeks, months, years ahead.
Rich: [31:18] I absolutely agree with that. From all points of view, when you talk about the stress and taking things away and emotionally, how you deal with things. We all come away in a better place with less questions of what if I had done this, what if, what if. For relatives that’s especially true. So what if. What if I’d noticed sooner, what if I’d called earlier. The last thing we want is for that “what if” to be about us as professionals. Seeing that order, having that leadership, and having that calm resuscitation going on that they witness and they see and also are a part of helps to alleviate that “what if”. They know they answer to the “what if” is that there is no “what if” because everything that could have been done was done.
Nick: [32:06] You’ve just reminded me of something, Rich, with the “what if” which is quite pertinent to dealing families and thinking about them beyond the immediacy. Often the scenario will play out that you’ve delivered some bad news and when the relatives have had some time to think about their actions, they ask you, “Could I have done anything else?” And of course, if we’re honest with ourselves, there will be some times when something could have been done that wasn’t done, but rather than being brutally truthful, I often try to remind them that the event was catastrophic, and couldn’t have been predicted, and focus on what they did do. Even if that’s just dialling 999 and us being able to get there quickly, rather than saying, “Well, you could have gone a couple of centimetres deeper and not had them on the bed.” It’s a tricky one, but we- and this is going back to how we can get better at this, we have to, in training processes, think about these sorts of questions that might come up.
Eoin: [33:15] Simulate these questions.
Nick: [33:16] Yes, exactly.
Rich: [33:19] You’re right, because then we’ll get better at this. These are very difficult questions in really emotional circumstances, and the only way you get better at that is by, like you said, by becoming experienced. And we can’t send more paramedics routinely to more cardiac arrests to get that experience so we have to somehow give them that through our own experience and learning, perhaps through this but also through a more formal education way by simulating that environment and those questions, so you’ve got that pre-loaded answer, almost.
Nick: [33:47] It is useful to have these off-the-shelf comments that don’t take up a lot of bandwidth to think about at the time. And I go back to this, you know, when you first enter the scene, being able to say who you are, what your name is, what you need to do, promise of an update, that sort of thing. I’m less keen on formal models. There are a number of them out there, there’s the grieving one. For me, to try to remember what the letters of an acronym mean at the time- I suppose one option is, before you speak to the relatives you pull it out of your pocket and have a look to make sure you’ve covered things. That’s an option. But trying to remember what the first “I” is-
Eoin: [34:32] I can barely remember my own name to be honest. Let alone- Yeah, I agree.
Nick: [34:38] Sometimes they can give you an awareness of what needs to be covered, but if you’re going to employ an acronym, you need to already have it in your head in certain situations, and that’s one of them, and not be reading it off of a card in front of relatives, because that has this disingenuous look about it. But there are some out there that are probably worth having a look at just to be aware of some of the areas that need to be covered in the arena of supporting families and breaking bad news.
Eoin: [35:14] Yeah. We can put some of those in the show notes. What I might do in the show notes if it’s okay with you, Nick, is put your paper in the show notes so that people can refer to your paper because I think it’s good as a summary document to re-emphasise. And we’ll put a few more papers in the show notes around breaking bad news and a few tools that people can employ and a few tricks of the trade. I think that’s an excellent overview. I resonate with everything you both said. I think we do need to simulate it more. I also think that some of the cancer patients in some of the oncology cases that I’ve been to have been some of the most difficult cases because-
Nick: [36:04] That could be a another podcast because they through up a whole set of their own unique challenges.
Eoin: [36:13] Absolutely, and it can be super challenging. But just to bring it back to a point you said, it’s about re-aligning expectations from a practitioner’s level. They are challenging technical jobs and they’re challenging non-technically as well. There’s two very succinct challenges. There’s the technical challenge and we’ve all been caught up in those challenges about the airway, the chest compression, the 360 access, but then there’s a whole subset of non-technical challenges. When it comes to its nth degree, and I was privy and witness to this a couple of weeks back, and I felt on reflection I couldn’t that much about it, it was a paediatric cardiac arrest, a 2-month old, and the resus itself was fraught with troubleshooting points that we had to troubleshoot. I could already hear the mother screaming in the background but because I really needed to address some key fundamental airway and breathing issues around securing the airway and getting good, systematic chest compressions, I felt really bad that I couldn’t get to the mother so quickly. It really typifies some of the hardest jobs because our bandwidth has been increased on these jobs and I’m so cognisant of the family member, especially when it comes to kids because the second patient really is the mother and father. Not being able to get to them when they’re having a melt-down, understandably having a melt-down, because you’re caught up in the technical skills, rightly so, it’s super challenging and I’m not sure there’s an answer.
Nick: [37:50] No, there’s not. This is part of my issue with set, algorithmic approaches. These jobs are so dynamic. We go to places we’ve never been before, meet people we’ve never seen before and deal with specific clinical presentations that we’ve never dealt with before, although that’s a sort of generality. It’s useful to have a hierarchy in your head. In that situation it sounds like you did the right thing. If you’ve got paediatric arrest and airway problems, that’s a no-brainer. Usually paediatric arrests do have an airway problem. I think offloading is something we need to do better at as lead clinicians. In London we’re quite lucky in terms of the number of resources we can throw, particularly at a cardiac arrest, my God, and our instant response officers or duty managers, operational officers as they’re referred to more generically, perhaps are the best people on-scene to provide that global overview, really stay non-clinical and deal with relatives. You have to be wholistic, don’t you?
Rich: [39:09] The challenge comes for me, and I think it’s alluded to in what you were saying, Eoin, that you walk into those scenarios as two people, almost. One is the advanced paramedic, the clinician, with the responsibility and the duty to deal with everything that comes with dealing with a cardiac arrest, and the other is the human being that’s walked into the room as a brother, a dad, a whatever, and part of you will always, as much as you will try not to have empathy with what’s going on, that’s natural and that’s normal, and those two people sometimes fight for primacy. You want to care for the emotional impact side of it but at that time you have other things you need to do as a professional, and balancing those two can be really stressful and difficult. Being kind to yourself, as you say, and saying I can’t do this at the moment, so I have to do this, but I know it, I know it’s there and I’m going to come back to it and I’m going to allow myself just a little bit of freedom to take that pressure off me and say I know I can’t do the human emotional bit just yet- and I think, Nick, you were alluding to it as well that you say to the family, “I’m going to come and talk to you but I need to just do these first.”
Nick: [40:19] Yes, and they can get that. And when they can’t there are strategies you can employ to move things on. And as I say, in a paediatric cardiac arrest I attended not so long ago, looking at the mother, saying who I am, what I do, what we need to do, please help me, (you know, recruitment), because we can’t save their life (explicit) unless you move back a bit. And it’s that compromise. And God, tearing a parent away from a sick child is probably not even right to do even if you could do it, so having them to one side, holding a hand, they’re seeing what you’re doing, seems perfectly right and humane. Tough jobs, aren’t they?
Rich: [41:17] Yeah, and it’s a fascinating subject isn’t it? How we do better at this, because there is no fixed answer and impiracly you can’t really gain data, can you? It becomes opinion, doesn’t it, and what we think we’re doing well and what we’re not doing well.
Nick: [41:32] Yeah. You can’t draw any hard evidence from this.
Eoin: [41:39] I think some of the fundamentals of what you’re both saying is through experience, through training, and through reflection through governance, this is where you come to some of the ubiquitous principles you were talking about.
[41:55] If we could summarise for the listeners, maybe five key take-home points for the listeners. I’ll start with the first one that stuck in my mind from what you were saying, Nick, and Rich, is be real. Be real with the relatives, be real with the family. Before that, clarify who you’re talking to but be real because they’ll see through anything you try to allude to which is maybe not the truth. So, be truthful and be real with the right people once you’ve clarified who they are. What else would you say?
Nick: [42:40] Try to set foot on the right foot, as the saying goes. It’s really hard to claw back once things- Not impossible, of course. Really hard to claw back. Going in with that introduction and with some sort of structure I think can help you move things along.
Rich: [43:09] For me, when you’re trying to deal with the relatives, as I just said, you can’t be that human and that clinician necessarily at the same time. Sometimes you can. If you need to split from one to the other, give yourself that cognitive offload. Find yourself a space within the resuscitation, if you can, once it’s established, and if you’ve got clinicians that you can offload some of the management to. Give you a bit of time and space then to go and be the human being in a different room and give yourself that space instead of trying to rush both or trying to do both at the same time. I think the stress levels are too high, you won’t achieve very well.
Eoin: [43:45] Absolutely, and something we were saying about externally processing it with a significant other be it your crewmate or your partner, be it your- someone close to you a good friend, just to get the frames of reference correct in your mind. It helps you to outwork some of that stress. And, like you said, Nick, be kind to yourself. Be kind to yourself. It’s a learning process and no one comes to a resuscitation fully equipped with feeling overtly confident in breaking bad news or controlling the scene. Generically, being kind to yourself. And one that’s come to my mind, what I try to do also is get people to sit down and I sit down with them at eye-level. I sit down with them at eye-level and what that does is it non-verbally gives them the impression- it may not be more time than standing up, but it gives them the impression that they have my sole attention. Sitting down with someone, there was an empirical study of doctors, of GPs, and the patients’ perception of you sitting down gives them the non-verbal cues that they have your sole attention. I always try to do that wherever possible. So if you can sit down, it really gives them the impression that they are the most important thing to you at that moment. I would definitely try to do that. At eye-level, so you’re not speaking down or up to people. You’re at eye-level, in their face, just sitting with them.
Nick: [45:27] And, (and this is perhaps my final word on the subject), practice it. These things do take some practice. We can talk about it and it all sounds very straightforward, sat in the luxurious comfort of this basement… If only we had a camera. But actually it would be nice to see this topic explored a bit more on educational programs and scenarios run that not just take into consideration, rightfully so, the clinical aspects of care, but also the other stuff.
Eoin: [46:00] Brilliant guys. I think that’s hugely beneficial and I think we’ve covered some really salient topics today. So thanks to Nick for taking the time out and sharing some personal stories as well and so this is me and Rich signing off.
Rich: [46:18] Good evening, morning, afternoon, whenever you’re listening. Hope you have a good day.
Eoin: [46:21] And good evening, morning, and afternoon from me, and we’ll speak to you soon.
[Outro]
Eoin: [46:34] This podcast was presented by Eoin Walker and Rich McGirr and any views we express are our own and this is a Medics.Academy podcast. The purpose of this podcast is to provide paramedics, nurses and doctors an easy to access set of resources wherever you are. Take a look in the footnotes of this podcast and sign up to Medics.Academy today to find out even more about what we do and how much content we put out there for your education.
Further Education
If you want to prepare as best you can for a situation where it’s on your shoulders to revive an infant in front of its parents, Will Broughton’s course, Essential Paediatric Assessment, is a great resource.
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