It Could Have Been Me

It’s not the first time I’ve felt overwhelmed by issues occurring just outside my sphere of practice. It’s definitely not the first time I’ve felt overwhelmed by issues occurring within my realm of clinical responsibility. And it’s certainly not the first time I’ve had a panic attack. It is, however, the first time that I have had to spend a good hour of a morning reminding myself how to breathe, because someone else has made a mistake. And if you don’t follow the news in the UK, I’m referring directly to the Bawa Garba case. And anyone practicing medicine in Ireland should review this case, study it, know it. Because frankly, it could have been any one of us.

I have been lucky. I am an introspective person by nature, and constantly reflect on my practice as a clinician. Difficult cases that I have seen, in which I have participated in the management are brought home, diagnoses studied, decisions all open to circumspect. I challenge myself to learn. And I know that there have been moments, events, split-second decisions that managed to pull a patient through by the skin of my teeth. Be it a result of something I knew, something a colleague offered, the senior on the other end of a phone said, the time of day, the waxing or waning of the moon; by chance, there was a positive outcome. That time an entire department was short 3 SHOs, because the posts were never filled. That time 2 colleagues phoned in sick and I was cross-covering for the daytime shift. The rotation where I did call as a registrar when I was only 12 months into my BST. All the new registrars, pulled early out of their SHO years for staffing reasons. The nights where the volume of patients outstripped the beds, the staff, the chairs in the waiting room, turning Dublin into something akin to a warzone. There are just so many of these moments that could have gone horribly awry, that it is overwhelming to think about them. Any moment could have gone differently. And they didn’t. And I am still here, listening, learning, keeping a critical eye on myself and my practice. And now I shudder to think that any of this reflective practice put in writing, perhaps even as far back as medical school, might be used against me when I finally find myself coming up short. When I am not enough for a patient. Because eventually, I will not be enough. And as of last week, if Ireland is to follow the UK as it is wont to do, when that happens, I could go to jail. I could be struck from the medical register. I could be blamed, publicly named and shamed, over one of the many things we, as a medical community, work tirelessly to prevent. Theoretically, this concept always existed. There is nothing theoretical about it now.

Let us be crystal clear in this: the systems in which we practice are insufficient. Since I have qualified, I believe I was EWTD compliant in one 3-month job. Since the Irish NCHDs went on strike to prevent shifts longer than 24 hours, I continue to be in hospital for stretches of 27 hours and longer. I have seen IT systems fail; new staff or locum staff arrive to work graveyard shifts without access to basic tests and radiology (let alone knowledge of where the loo is); I have stayed late, arrived early, worked doubles, covered for two or three colleagues, faced verbally and physically abusive patients and family; I have witnessed loss; I have grieved; and I am exhausted. All of this, and I work in a field, a discipline and hospital that are some of the best supported and most supervised across the health service. I know I’m well minded. And yet…

We as NCHDs are still growing and learning. We are apprentices in a system designed to education through exposure, supervision, and mentorship. And we are now facing a system whose neighbor and mirror has suddenly deprived a single member of supervision, support, staff, supplies, and mentorship and subsequently blamed them when they weren’t enough. It is simultaneously outrageous and horrifying. It could have been any one of us. Frontline staff is crippled by systemic shortcomings, bone-weary, occasionally suicidal, and now scapegoated. Forget discussing reflective learning and work-life balance, where is the compassion?

This brings up another concern, issue, bugbear, ill-comparison that must be stopped. The medical system is not like the airline industry. Can we please all accept this? “You wouldn’t take off in a plane without a co-pilot…” No. No you wouldn’t. But at what point is an ED in take off mode? The ethical dilemma when staffing is short is never, “should I refuse to work in this environment,” it’s, “how do I help the most patients when we’re this short.” We aren’t doing takeoff and landing safety checks. We are in the air. Constantly. Non-stop. Refueling mid-flight. Slowly running out of supplies and rested crew. We are not an elective, consumer based industry. Health is not a business. Patients are not consumers. These are people trying to help people through the scariest and worst moments of their lives (occasionally the scariest and best moments of their lives). Perhaps instead, we are much more like the military (I know, I know… delicate subject to raise in a neutral country). But we are in a situation where we must function 24/7, no break, no gaps in the functionality. People are at risk of dying; we are working to prevent that. It’s an old, hierarchical system, full of tradition and excess and out-dated equipment and algorithms that are near impossible to improve at any speed. And bottom line is the single, exhausted, junior crew-member standing lookout at three in the morning can be, often is, the one thing guiding the ship between success and death. Consider again the frontline staff and how they are treated…

We are haemorrhaging medical staff. Doctors and nurses leaving the country, leaving the continent, leaving the industry all together, because it is no longer worth the toll to stay in their vocations. Burnout is soft word for PTSD. The system is broken and now the blame game has begun. No one person can possibly bear the burden of an entire health service and no one person should. I’ve been lucky. It could have been any one of us. I’m sure it’s already been me.