2 December 2021
When the trauma patient is the doctor
On 7 June this year, I ceased being an emergency physician.
My FACEM (Fellow of the Australasian College for Emergency Medicine) post-nominal was operationally retired. So, a timely reflective piece is in order.
This narrative details how I became a “secondary victim” and grew as a result. It is neither a hero’s saga nor a pity-me story. I now know it to be a theme on continuous loop, somehow and somewhere, for many.
In 1967 I was an intern working alone on the weekend in a regional hospital. I was called to “attend” to a 16-year-old lad who had intentionally blown away his face with a shotgun. I knew immediately that I was out of my depth and that my “attending” was futile.
I had mistakenly allowed myself to believe that in this situation, I could call for support and it would promptly arrive. My support arrived, but in the form of a not-so-cryptic “don’t be afraid to cope”. As it was, I didn’t cope.
The young man’s family and friends were of course the major secondary victims. Relative to them, my victimhood was minor. Yet to me, it was real and highly significant.
What followed was a three-day memory dark-out. I know that I was there and somehow functioned, but I was rendered a zombie automaton. My fight-or-flight response was flashing red and overloaded. My consciousness centres (amygdala and hippocampus) must have been fried. A thing some call PTSD was fated, but still a long way off.
I’m still not sure if it was the witnessing of a senseless death, the sleep deprivation that came with the job, or the intense sense of betrayal caused by the denial of expected help that thoroughly rocked my boat.
I felt totally responsible for his death because to me in that instant, my resuscitation skillset was patently deficient. My consequent guilt overwhelmed me to the point where an inner voice told me that the only honourable way out was to kill myself. I was not prepared for what I now know is the insidious secondary trauma associated with suicide. I had no idea then that suicide could act as a contagion for others.
How did I arrive here?
I was not one of those who are blessed from an early age with a burning desire to build bridges (engineer), defend the oppressed (lawyer), nurture the young (teacher). I was just a curious kid who happened to do well at high school, earning a commonwealth scholarship and university prospects. But I had no idea of what career I wanted. My Dutch migrant father’s only tradable skills were a devil of a work ethic and the courage to take risks. There were no doctors in my pedigree.
So I made a pragmatic choice. I ticked the boxes in what I understood was the order of difficulty: veterinary science first, medicine second, law third. As it transpired, I was not smart enough to be a vet but too smart to be a lawyer. Medicine it was.
But there was a Plan B codenamed prudence: if it wasn’t fun or proved to be a bad fit, I could always move down. This was a better option than attempting to move up.
After my emergency room crisis, it was my Plan B that saved me. After three days of driving to work while resisting an inner voice beckoning me to accelerate into a roadside tree, I decided that this medicine thing was a bad fit and I was definitely not having fun. I do remember saying it was time to be a farm labourer. I resigned.
My father was not impressed, and whisked me to the professor of psychiatry, who reframed my story: “You’ve been thrown from a horse and the sooner you get back on the better.” He secured me a position in a city tertiary hospital intensive care department and arranged follow-up for the following Monday. Farm labouring would have to wait.
That Monday morning, I reported for duty to discover that the good professor had been admitted to my ICU with a traumatic brain injury. He was dysphasic. Instead of him caring for me the roles had been reversed. There was no follow-up, but I now had the inner stirrings of a purpose.
My purpose had three pillars. First, to become the fastest tube putter-inner in the west, regardless of the orifice; even for those without a face. I sought to never feel powerless again in the heat of a medical resuscitation.
Second, to seek out others who believed that the pervading culture of requiring the most inexperienced doctors to care for the sickest patients as a rite of passage was ethically repugnant.
Third, to prosecute the case that the provision of pastoral care for junior doctors was a lay-down misère and that the resilience training being foisted on young doctors was no more than victim blaming. The mental health lens then being applied was counterproductive and a one-way ticket to stigma and shame.
How did I do?
What does my personal audit look like?
Regarding the first pillar, my transition to critical care gunslinger was complete: Doc Holiday would have been proud.
For the second, it wasn’t hard to find others with a similar dream. As secretary for the nascent Australasian Society for Emergency Medicine I was a junior partner in the genesis of the Australasian College for Emergency Medicine (ACEM), contributing enough to earn my foundational fellowship.
The third pillar remains a major work in progress. After 35 years as a FACEM, 12 years as a director of clinical training and a mentor to dozens of trainees, I have noticed that it is the “sensitive” who more often falter. I have heard some crusty old veterans say that they have “too much empathy to be healthy”. I find that sad.
My early teachers in medical school taught me that the best medical care from a patient perspective was a sweet spot found between the science, the craft and the art of medicine. The art is to be found in the shared humanity.
Looking back, I have nothing but gratitude. Sure, in my ledger there is great heartache as well as great joy, and there was a mid-career burnout and a delayed diagnosis of PTSD and depression. My mother told me once that to grow I needed to fail spectacularly and often. If I have any wisdom at all it is because of my abundant mistakes. But I am still grateful. I am beholden to my anonymous patient horde who gradually transformed me into a human first and a doctor second.
The ACEM curriculum will always be both clear and arcane, but here are some basic principles which inform it. If one of your patients dies by suicide, you are not alone in experiencing emotional turmoil, perceived isolation and guilt. Shame and secrecy should have no place in it. Sunlight is the best sanitation. Empathy is healthy. Grief is the price we pay for love and humanity. Guilt is a sign that we are good. The stories we tell ourselves are the key – you are you at your best when they are shared honestly. Your stories are important, but they do not have to permanently define you. They contribute to your growth.
With amity I pass on the baton. As a retired Fellow I remain entitled to use the post-nominal and I will do so with pride.
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg; he continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School; he is also a poet and songwriter