Author: Ryan Ghodrat / Editor: Nikki Abela / Codes: SLO11, SLO12, SLO2, SLO8, SLO9 / Published: 27/03/2018

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After 5 years of guilt free pleasure outside of NHS working on the cruise ships and providing ad hoc locum work in local EM departments for a pretty sum (to pay off an ugly mortgage), I am approached by one of my consultants who says, “you’ve had your fun, but now it’s time to grow up”. I admit the thought of working the same job for half the pay and less flexibility didn’t seem too attractive at first, but then again it would be nice to finally be called a consultant.

Having successfully landed an ST4 training post, I start my first job in a small, yet busy, rural ED in Merseyside. I am excited and enthusiastic about this new training job and I enjoy exchanging stories with my colleagues who later fill me in on all things e-portfolio.

A few months into my attachment things aren’t quite as light and fluffy as they once were. Impending “Winter Pressures” have arrived in fine form, with once empty corridors now replaced by reams of trolleys filled with sick patients, accompanied by hawk-eyed relatives and disgruntled paramedics eager to get back on the road.

What was once considered an exciting challenge, is now viewed as a lost battle, where chronic understaffing and serious underfunding continue to ask all of us to give a little more each and every day.

Outside of work my personal life is no better. The things in life that used to give me so much pleasure like playing squash and going out for drinks with the boys was slowing being replaced by social exclusion and a constant need for sleep.

I pack my bag for the weekend nightshifts. As I pull up outside of the ED I see a queue of ambulances outside and walking through the waiting room, not a single empty seat. Tonight’s going to be a tough one. No sooner have I walked out of the changing room, has an ECG been cast in front of my to check.

As I work alongside my colleagues to tackle an 8 hour wait, one of the nurses states that a 24 year old woman who has taken a mixed OD of antidepressants wants to discharge herself and that security are currently with her.

I ask the mental health (MH) nurse to accompany me for a capacity assessment. When we get there, the young woman has her hoodie up and barely makes eye contact let alone participates in conversation. Fortunately the MH nurse is free to sit with our patient and finally brings her round to the idea of having bloods taken and staying for a cup of tea and a sandwich. This victory is short lived when I am later informed that she has run away leaving behind her an iphone and personal possessions.

Half an hour later I take a stand by call. “Young woman found hanging from a tree, in cardiac arrest. ETA 5 minutes”. My worse nightmares come true as I find myself team leading a resuscitation effort for the young woman I had spoken to only moments before.

Fast forward to my final night shift. I wake up in my dingy hospital accommodation and do the slow walk of a man who looks like he is on his way to the electric chair. The cold, dark corridor leading towards the ED is the final opportunity I will have alone with my thoughts before putting on this mask again in front of others. A feeling I have felt for quite some time now.

The night passes and it’s finally over, I hand my patients over, throw my hoodie on and drag my feet to the audit department to discuss one of my personal projects. When I arrive I suddenly experience a strange feeling.

My head is now a lead balloon and the room is swaying in motion. A sudden sense of nausea washes over me and I need to vomit. They point me in the direction of the toilet and I bounce off the walls like a drunken buffoon before redecorating the bowl.

The audit team offers to take me back to A&E but that isn’t happening. I just need to sleep this off. I ‘drunk walk’ my way back to my hospital room, neck a pint of water and go straight to bed. I wake up and thank god I feel back to normal, except for a mild headache.

Over the next 5 days I just cant shift this headache. I phone up a friend (another EM Registrar) and tell her, “I had a near collapsing episode 5 days ago at the end of a night shift and I’ve had this headache since”. The penny drops. Before I can answer my own question, she lectures me on how stupid I am and insists I get to A&E immediately for a CT scan. My friends are on shift and before I can even sit down I am being summoned to the CT scanner. My worst fears materialise as I ask to see my scan and notice a large black spot over my left cerebellum. I’ve had a stroke!

Unfortunately I’m not cool enough to blame this on a sex, drugs and rock’n’roll lifestyle. Was I just unlucky? Or was it stress-related?

The truth is that having being diagnosed with a ‘Cryptogenic Stroke’, I’ll never know. However, I feel very fortunate to be able to state that I have made a full recovery. Although my CT scan will always serve as a constant reminder of the dangerous effects of stress and depression. Following some regular NHS funded counseling sessions I now work 80% LTFT and feel much happier in myself, which additionally allows me to be a better doctor to my patients.

So why tell this personal story to thousands of strangers via social media? Is it the catharsis of putting thoughts on paper and making sense of recent events? Perhaps. But more importantly, I feel ‘Burnout’, ‘Stress’, ‘Depression’, or whatever you want to call it is extremely difficult to define. Although we are probably more qualified than most to diagnose these conditions in others, there is a personal pride that clouds judgment in the diagnosis of self.

Unfortunately my story is not unique and I would bet serious money that we can all account variations of this story during at least one part of our careers (junior or consultant). Chronic exhaustion, mental slowing, impaired concentration, compassion fatigue were all telltale signs I was experiencing burnout.

So what is burnout? This is a difficult question as no one has been able to agree on a formal definition. Furthermore, if this is impossible define, how can we diagnose this in ourselves? Interestingly, burnout has also been labeled as ‘Overachiever Syndrome‘. From this, I would conclude that doctors of all specialties are at risk just through recognition of their prior achievements. However, burnout is not unique to healthcare, with many other industries including banking, teaching and sales being equally at risk.

Extremely hostile work environments with long waiting times, increased patient expectations, poor staffing ratios and the sickening sense of guilt felt examining patients on public corridors, clearly all play their role in burnout. So what can we do? Our environment is unlikely to change given the yearly trends, so we need to look elsewhere if we are to help reconcile this problem.

If you type ‘how to deal with anxiety / depression / burnout’ into google you’ll likely read a variety of self-help advice, including the importance of healthy eating and drinking, the need for adequate sleep and the physiological benefits of daily exercise, as well as the increasingly popular practices of meditation and mindfulness.

Although I believe all of these are important, it does strike me as the metaphorical equivalent of telling prisoners in Guantanamo Bay that they can maintain a healthy outlook on life with lots of self-practice and daily scheduling. In other words, perhaps changing the work environment is a better method of tackling this problem.

The NHS is the biggest employer in the UK, yet employee morale and team building is very low down the agenda (probably for financial reasons). When I worked on the Cruise Ships we had a dedicated Crew Welfare Officer whose primary responsibility was to organise regular social events and I would argue their job was among the most important.

So instead of self-help here are some other practical ways that may provide everyone with ‘Burnout Prophylaxis’:

  • Arrange Team Building Sessions

Try to create a social committee (Consultants, Trainees and Nurses) in your ED for everyone. Organising a meal, activity or just drinks once a month will allow everyone to get to know each other on a more personal level.

  • Motivate your Team Regularly

Try to engage everyone that you meet. Learning what is going on in other peoples’ lives is at the very core of a community spirit and is likely to lead to better conversations than those regarding busy wait times or work politics.

  • Set Clear Goals

All humans need personal goals to maintain high self-esteem and grow as individuals. Want to learn EM Ultrasound? Practice. Want to be a better Trauma Team Leader, insist on being watched. It’s all your responsibility!

  • Show Appreciation

Tell your juniors that they’ve done a good job. Make notes of excellent practice and feedback to their supervisors. In some hospitals they have A&A (Amazing & Awesome) or Greatix reporting systems to highlight excellent practise.

  • Create Positive Competition

A&E versus AMU 5-a-side Football? Inter-hospital Tough Mudder? I’ve even heard of Major Incident Training where other hospitals send enclosed envelopes to other hospitals with secretive Major Incident Scenarios… Nasty, but fun!

  • Be Inspirational!

All of these ideas above require action. It’s easy to wait for others to organize events, but leading by example is the sure way to promote change in a longstanding culture.

Links are attached below for more advice on burnout, anxiety and depression. If you feel that these issues apply to you please remember as an NHS employee you have access rights to free counseling through your lead employer. It’s free, and extremely helpful!

Most importantly, look out for each other!

Further reading/resources:

You Got This

BMA Oldenburg Burnout Directory – Questionnaire 

Liz Crowe at St.Emlyn’s – Burnout in Critical Care

ED Spa at St.Emlyn’s 

Daylio App – Mood Tracker

Naturally online resources can only help so much and if you feel your mental health is having a major impact on your daily life or your ability to provide quality care to your patients, I would strongly recommend contacting your local occupational health department for a personalised assessment.