As usual, we were very impressed by the rich commentary and discussion that evolved over the week. We are now proud to present to you the Curated Community Commentary and 2 our two expert opinions. Thank-you, again, to all our participants for contributing to the very rich discussions last week.
This follow-up post includes
- The responses of our experienced clinician experts, Dr. Hans Rosenberg (@hrosenberg33), and Dr. Tessa Davis (@TessaRDavis).
- A summary of insights from the ALiEM community derived from the Twitter and blog discussions
- Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
[su_spoiler title=”Expert response 1: 3 Steps for a Smooth Debriefing” style=”fancy” icon=”chevron-circle”]
Hans Rosenberg, MD, CCFP(EM)
In the field of Emergency Medicine most of us would have encountered a similar experience as that of Melanie. Our work can be often seem like the routine intermixed with moments of chaos that can leave us in a fragile emotional and psychological state. A case such as the one described is capable of doing just that. So as an attending/supervising physician there is a clear role in this case for debriefing with our learner. I’ll briefly discuss a suggested approach to debriefing and how it could play out in real life.
Debriefing is an integral process in learning which allows for discussion and analysis of an experience, evaluating and integrating lessons learned into one’s cognition and consciousness [1]. The debriefing approach that I prefer to use is a be a 3-step approach described by experts from The Center for Medical Simulation in Cambridge, Massachusetts [2]:
Step 1 – The reactions phase
At this point it would be important to allow Melanie, as well as any other participants in the case who would also like to participate, to be able to “blow off” some steam and let out their emotions about the case. In our particular scenario there are appears to be a mix of shock, sadness and perhaps feelings of inadequacy. This is the time to “normalize” both the emotions that Melanie is experiencing, as well as the case that she had just seen. If applicable, this would be the time when the supervisor can share a similar experience they had at some point in their training as part of the normalization process. Additionally, the facts of the case should be explicitly reviewed at this time.
Step 2 – The understanding phase
This step is when Melanie would be given the opportunity to describe her frame of mind, how that led to a certain action and what the results were. For example, Melanie may mention that although she had previous knowledge of how to perform Cardio-Pulmonary Resuscitation (CPR) she had never performed it on a person. The resulting sensation of ribs fracturing under her hands led to a distinctly negative experience and did not yield the results she may have hoped for or expected (ie. successful return of spontaneous circulation). This is also a time when the debriefer would make explicit what’s on their mind in order to clarify certain points and encourage discussion. In our case, a statement such as “I was pleased to see that you had excellent technique during your performance of CPR, it was at the appropriate rate of 100 per minute and the ideal depth.” This has a two-fold effect of letting Melanie know what she did correctly and the rationale behind it.
Step 3 – The summary phase
At this final step, it is time to allow Melanie to tell me what she thought she did well, what she would do differently and how she might implement it in the future. It is a simple, but often overlooked skill to be able to reflect on actions and make a plan which they can be acted upon if a similar scenario were to arise.
This approach would be helpful in dealing with the debriefing of a young learner such as Melanie being exposed to what can be a very traumatic experience. However, that should not be the end of the discussion. It would also be important to gently remind her what a profound effect these types of cases can have on health workers and that she is not alone. There is clear evidence that exposure to critical incidents is associated with post-traumatic stress symptoms, anxiety and depression [3]. As such, it would be wise to ensure that there can be some follow up in the near future to see how Melanie is doing. It doesn’t have to be formal, but support from colleagues/supervisors can have a protective effect when it comes to the negative outcomes associated with critical incidents [4].
References
- Lederman LC. Debriefing: towards a systematic assessment of theory and practice. Simulations Games. 1992;23(2):145–160.
- Gardner R. Introduction to debriefing. Seminars in Perinatology. Elsevier; 2013 Jun 1;37(3):166–74.
- de Boer JC, Lok A, Verlaat EV, Duivenvoorden HJ, Bakker AB, Smit BJ. Social Science & Medicine. Social Science & Medicine. Elsevier Ltd; 2011 Jul 1;73(2):316–26.
- Adriaenssens J, de Gucht V, Maes S. International Journal of Nursing Studies. International Journal of Nursing Studies. Elsevier Ltd; 2012 Nov 1;49(11):1411–22.
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[su_spoiler title=”Expert response 2: Debriefing Models” style=”fancy” icon=”chevron-circle”]
Tessa Davis, MBChB, MA, FACEM
This is an emotional and difficult situation whether you have been working in medicine for 2 days, 2 years, or 20 years. However, as a medical student Melanie is in a particularly vulnerable position because she has no previous experience or preparation.
A debrief is needed to allow staff to feel comfortable opening up about their reflections. This might include practical points such as finding a private area to debrief; making sure all the staff have space to sit and are facing each other; and noting that everyone in the team is a potential valuable contributor [1].
Debriefing Models
There are several models for debriefing. The most common is the Critical Incident Stress Debriefing (CSID) model, created by Mitchell in 1983 [2] and elaborated on by Dyregrov in 1997 [3], which includes 7 stages:
| Stage | Description |
| Introduction | Introduce the team members, set out some guideline for the debriefing conduct |
| Facts | A very brief overview of the facts |
| Thoughts | “What was your first thought?” |
| Reactions | Aiming to transition from ‘thoughts’ to ‘symptoms’ by asking “what is the worst thing about this for you personally?” |
| Symptoms | Team members listen to other people’s emotional or physical symptoms and contribute theirs |
| Teaching | Normalising symptoms, explaining reactions and teach about stress management and any topic relevant to the specific case |
| Re-entry | An opportunity for any other questions or statements. The team summarises the discussion. |
Others include Kinchin’s emotional decompression model [4], which uses a diving analogy with stages being:
- Diving in
- Deep water
- Middle water
- Breaking the surface
- Treading water
There is also the 5-stage SHARP medical model [5]:
- Set learning objectives
- How did it go
- Address concerns
- Review learning points
- Plan ahead
The General Concepts
All of the above models (and there are plenty more) encompass the same key points:
1. Establish the facts
Outline what happened with this patient, the medical elements of the resuscitation, and how the case progressed. Often in times of high stress, the facts can get blurry in our minds. Stating the facts out loud at an early stage can help provide an accurate memory of the situation.
2. Address thoughts and feelings
It is important to discuss people’s thoughts and worries. This medical student is having the same reaction we all do when faced with death: Did we do something wrong? Could we have done something differently that would have led to a different outcome? Often, a specific element of the resuscitation can become the focus. A senior doctor may worry about his intubation skills and if he could have been faster; a junior doctor may worry about the time taken to recognize how unwell the patient was; a medical student may worry that she wasn’t doing the CPR correctly and that her fatigue brought about the patient’s death.
It would be more helpful for Melanie to be allowed discuss her specific worries openly rather than just giving her a dismissive ‘of course you didn’t do anything wrong’. Asking what her concerns are, and perhaps even discussing the role she played throughout the resuscitation, will help her to decompress.
3. Discussing our own symptoms
I think we all have a patient that suddenly flashes into our mind in the middle of the night, or even in the most unexpected situations. That’s a normal part of being human and coping with our day-to-day working lives. However, if these thoughts or feelings are affecting our work, sleep or personal life then they may need some additional support. Post-traumatic stress disorder is described in healthcare professionals after witnessing stressful events and the healthcare team needs to be vigilant to the signs and symptoms.
Be cognizant of humanity and grief. ED staff have a tendency to just ‘grab a coffee and pull themselves together’, and many find it challenging to confront emotions during debriefs. However, there is clear evidence of the psychological effects of resuscitations on doctors [6], so it’s essential to acknowledge this.
4. Learning from our mistakes
As doctors we are always learning from our patients – we can always do better next time and identify learning points. Resuscitation scenarios can often highlight systemic flaws in the department: equipment that is not available or complete; problems with drug access; or difficulties with communicating with other staff members. The debrief helps to establish whether there are changes that can be made to improve the system in the future.
However, as a medical student who is not expected to have expert resuscitation skills, the main purpose of the debrief for Melanie is emotional support.
5. Summary and follow-up
A debrief usually happens pretty close to the event (although the CSID guide reference above suggests 24-72 hours post-event). This is often for practical reasons – getting together the same staff at another time in a shift-working environment is near impossible. It is useful to talk about the resuscitation while it is fresh in everyone’s mind.
Follow-up is also important. After time for reflection, Melanie may have other questions and other thoughts and it’s essential to address these. Arrange to meet Melanie again and let her know of any follow-up case meeting, for example if the case is being presented at an M+M meeting.
References
- Salas et al, Debriefing medical teams: 12 evidence-based best practice tips. The Joint Commission Journal on Quality and Patient Safety, 2008, 34(9):518-527.
- Mitchell JT. When disaster strikes…The critical incident stress debriefing, Journal of Emergency Medical Services, 1983, 13(11):49-52.
- Dyregov A. The process of psychological debriefing. Journal of Traumatic Street, 1997, 10:589-604.
- Kinchin D (2007). A Guide to Psychological Debriefing: Managing Emotional Decompression and Post-Traumatic Stress Disorder London, UK and Philadelphia, PA, USA: Jessica Kingsley Publishers.
- Ahmed M, Arora S, Russ S, Darzi A, Vincent C, Sevdalis N. Operation debrief: a SHARP improvement in performance feedback in the operating room. Annals of Surgery. 2013; 258(6), 958-963.
- Dyer K. The potential impact of CODES on team members: examining medical education training, American Academy of Experts in Traumatic Stress, accessed online on 27th March 2014.
Other Resources
- The London handbook for debriefing, Imperial College, London, 2010, accessed online on 26th March 2014.
- May, N, It’s good to talk – debrief in the emergency department, St Emlyn’s Blog, accessed online on 26th March 2014.
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[su_spoiler title=”Community Commentary” style=”fancy” icon=”chevron-circle”]
by Teresa Chan, MD, FRCPC, MHPE(c)
This week, we had a similarly significant online discussion about this case. As I read, there were a number of themes that emerged from your comments. We have chosen to highlight some key issues for learners and faculty members to consider when you encounter a situation that may require a debrief.
What might you actually say?
Dr. Woods suggests that attendings can facilitate debriefing by asking a simple question: ‘[T]hat was a tough shift, is there anything you want to discuss?’ Letting, the conversation, thereafter, be steered by the learner (Melanie) and her needs.
Dr. Loice Swisher outlined her actual answer to the question of how one might approach Melanie:
“If you do this long enough you will make decisions that cause a patient pain, suffering and death- probably more than once. It is even more problematic in emergency medicine where we have to make rapid decisions with inadequate and incomplete data often having no established prior rapport with the patient or family. Yes, to err is human. Medical mistakes are now thought to be the 3rd leading cause of death in the US. However, Melanie, for you this is not one of them. You acted admirably at the level of your training. The outcome is not your fault. At this stage you need to recognize the difference of sick and not sick and when you are in over your head needing help. You did that.”
Jeffery Hill suggests starting with something akin to: “No matter how long I’ll work in this job, I’ll never get used to the death of a young patient.” He then described how he would reaffirm the things that Melanie did very well: First, she recognized sick versus not sick and second, she realized that the resources present in the room weren’t sufficient to care for the patient.
Others spoke in more general terms about their approaches. Some would provide Melanie with a break, while others suggested they would explicitly ask Melanie how she was doing (to create a safe space for disclosure). A key in this process seemed to be to normalize that emotions and responses were a natural part of post-resuscitation proceedings.
The importance of debriefing to prevent the ‘Second Victim’ effect: Learners, attendings, and everyone involved
The concept of the ‘second victim’ was introduced to our conversation by Dr. Chris Merritt, who worried that we often downplay (or forget altogether) the healthcare practitioners that are involved in the resuscitation. Junior colleagues, nursing, clinical staff, and non-clinical staff alike may need support after experiencing a ‘tough’ resuscitation.
Many learners disclosed during the discussion that they often feel alone during the post-resuscitation period. Several noted that it is important for learners to feel supported and discuss cases of importance whenever possible. As Dr. Luckett-Gatopoulos states:
“I suspect that experienced clinicians know when they are and are not to blame, but learners nearly always feel that they have had something to do with the outcome, especially since we often do not understand the intricate details of the situation.”
Several participants pointed to the concept of post-traumatic stress disorder, and how it might be important to institute ideas around critical incident stress debriefing (CSID) Of critical importance is the need to debrief with the entire resuscitation team, and provide follow-up.
The worry, however, was that in having a standing CSID procedure that occurs immediately after every resuscitation, team members themselves may not be ready to perform this task in the immediate future. As Loice Swisher notes,
“Looking at the case, I don’t think that Dr Berner could do a great clinical/cognitive debrief anytime in the near future. I think it will take some time to work this through himself and then decide how to incorporate what is learned into a their own clinical framework.”
The idea of a CSID team was a novel idea that not many commenters had experienced. Both Drs. Robert R. Cooney and Dr. Teresa Chan described the idea of a bare-bones debrief after a code, asking a few key questions:
- Is there anything we missed?
- Is there anything we could have done better?
More constructive and larger avenues would be to use a more systems-level thinking via an M&M case. Dr. Cooney suggested the Vanderbilt matrix to facilitate this [1,2].
Dr. Merritt describes how their team uses both an ‘in-shift’ debriefing and then an organized session several days or even weeks later – but then describes how the temporally distanced debrief may lose impact.
The importance of being earnest… and having empathy
Empathy is a critically important skill in the setting of debriefing and bad news. Dr. Rob Woods (Univ of Saskatchewan, @RobWoodsUofS) highlighted that if a case seems clinically ‘clear-cut’ (e.g. an elderly patient, with significant co-morbid disease), we might overlook how stressful that can be for a trainee. Dr. Stella Yiu similarly highlighted the need for experienced clinicians to listen and normalize feelings, since junior colleagues may not have a large body of experiences to draw from.
An underlying tone of some of the comments was that sometimes we, as emergency practitioners, treat death and dying a bit mechanically – as a code to be run. Dr. Loice Swisher explained how a personal friend and situation helped her remember the impact of your words on your patient’s family:
I had a good friend whose mother and brother were killed in a motor vehicle accident after leaving his house for Thanksgiving dinner. I wasn’t even in medical school at the time when he told me how “the ER doctor came in and quietly tore his life apart”. I think of my friend and that phrase every time that I notify a family of a death. That is my private moment of silence and reflection.
Dr. Nadim Lalani, explained his technique for holding a moment of silence at the termination of a resuscitation. This seems to have been taken up well by the team in his department, and may be of benefit to other teams.
Many participants also endorsed the involvement of family presence during the resuscitation. As has been described in the literature previously [3], this technique does help with the family’s grieving process. But, as Dr. Luckett-Gatopoulos noted, it is quite unfair to ask those without specific training to support a family through a resuscitation. If we are to care all members of our team, we should equip them with the skills to be able to handle the family presence. As such, Dr. Robert R. Cooney noted that he is only able to provide the family the opportunity to be present during resuscitation if there are trained individuals present that can carefully facilitate this process.
That awkward moment when you realize you need to talk and no one is around
Many participants noted that this case seemed to have affected both Dr. Berner and Melanie significantly. As such, it was agreed that both needed to talk about this case with someone.
Some learners perceived that they have had to request debriefing, and still others noted that they have felt the need for one, but didn’t know how to ask. In fact, some participants noted that Dr. Berner (the attending for the code) may be in need of a good debrief, too. As such, would he even serve as a good ‘debriefer’ for Melanie? This issue was left unresolved by our discussion, but highlights a important issue for discussion: What debriefs the lead clinician?
A few participants highlighted the need to create a supportive network, people with whom you will discuss cases that bother you most. Some found their friends to be of importance in their personal debrief, others debrief openly in formal settings (e.g., Morbidity and Mortality rounds), whereas others found that discussing cases with a mentor helped. Drs. Yiu and Swisher both described how they had a few choice colleagues (e.g. ‘work spouses’) that serve to support them.
A call to action: Training learners and staff to debrief
Many participants noted that they had little formal training in debriefing, but have learned on the job, or by an apprenticeship model (e.g. viewed others’ and emulate). As stated before, though there is evidence [3], that family presence during CPR has benefit for the family members, there may not be capacity in your local milieu to provide this service.
At least one medical school (Queen’s University, Kingston, ON) seems to have a narrative medicine course (Medicine and Literature) that serves as a platform to discuss learners’ feelings, concerns and uncertainties. Indeed, it seems the fictional works they discuss precipitate reflection, and perhaps the MEdIC series itself is a proof of this method.
Regardless, the avid discussion this month is testament that this is critical issue that needs to be discussed and then acted upon.
So, I leave you with this – what’s your local plan for debriefing critical incidents? Do you have one? If not, is it time to think about it?
References
- Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG. Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):98-105.
- Cooney, R. Making M&M Better: The Healthcare Matrix. From the Better in Emergency Medicine blog. Accessed last on Oct 30, 2014.
- Jabre et al. Family presence during CPR. N Engl J Med. 2013 Mar 14;368(11):1008-18.
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Case and Responses for Download
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