FOREWARD

This e-book is for anyone who works in health and would benefit from the
reminder that they are important. That part of being a great clinician, or
partner or parent or friend is taking the time to care for yourself. Putting
your own ‘oxygen mask on first’ so that you can be available to bring your
skills, compassion and energy to others.
There is no doubt that working in any area of medicine can at times be
tough. What makes it tough or challenging can vary over time, it may be
shift work, fatigue, patients or colleagues. It may be when we are studying
and trying to work, or even because of what is happening for us personally.
Critical care medicine, particularly emergency medicine is staffed by
incredible people who are prepared to work in the time critical and
information light world of emergency care. Our world at work can be
exhilarating, meaningful and at other times stressful and hard. Sometimes
our workloads are overwhelming and there are days when it feels difficult
to cope. Yet for most of us this is a job we love and enjoy and we are
committed to doing it for the duration of our working lives. Some of us
even thrive on the pressure and challenges!
However, we cannot ignore the very real pressures and grief we
experience in our working lives. It is our goal at St Emlyn’s to work with
you to find strategies and information that may help you to not only endure
but flourish in this work. To be comforted that in those times of struggle
and disillusionment you are not alone and that you can recover.
In this e-book we have collated the collective wisdom of the St
Emlyn’s team on how we have approached some of the many challenges
that we face in building a career, a family, a home, a reputation and a
lifelong love of what we do. This e-book is divided into chapters tackling a
cornucopia of topics related to wellbeing and resilience.
 There is no particular way to read the book and we invite you to
choose where to start and finish. We also invite you to share this book with
your friends and colleagues, if this book helps just one person on one day
then we will know it’s been worth it (you can email us or tweet us if you
feel like it).
Whilst aimed at, and largely written by emergency clinicians we
believe that everything here is relevant to all clinicians who work in acute
specialities. All the chapters in this book first appeared on the St Emlyn’s
blog and podcast and we will continue to publish there on similar topics
then we will know it’s been worth it (you can email us or tweet us if you
feel like it).
Whilst aimed at, and largely written by, emergency clinicians we believe
that everything here is relevant to anyone who works in acute specialities.
All the chapters in this book first appeared on the St Emlyn’s blog and
podcast.
If you want to keep up to date with our work then please subscribe to the
blog and download the podcast.

vb
Laura Howard and Simon Carley
Chapter 1- Written by Liz Crowe

BE WELL AND BE A BETTER CRITICAL CARE CLINICIAN

This blog supports a recent podcast with Iain Beardsell on wellbeing for
clinicians. Although this is not the sexy resus end of critical care or
emergency medicine, it’s really just as important. You can only be a great
clinician if you look after yourself. You can hear the podcast by clicking on
the link below.
Working in critical care is challenging on us – physically, emotionally and
spiritually. The work is mentally difficult, technically challenging and at
times emotionally draining and incredibly sad. So how do we care for
ourselves? Despite being incredibly clever very few people in critical care
have a Wellbeing Plan. Strategies and tools in place to ensure that each day
they are committed to their own wellbeing so that they can remain present
and available to their own loved ones and also to their patients.
Critical care staff who are well across the three domains of physicality,
emotionally and spiritually will provide higher quality and safer care to
their patients, be better leaders and team members, more likely remain in
their role and be happier – why would we not attend to our own wellbeing
then with urgent attention?
What does a wellbeing plan look like then? It has to cover all of the
essentials and requires almost a painful awareness of self. It should be
consistent enough that it is a lifestyle approach and a routine that you
adhere to every day. Dynamic enough to change and be flexible depending
on life circumstances and it has to work for YOU. A wellbeing plan must be
something that works for you and your personality and life. We all know
what we should do but know we have to integrate this into what we can do.
Sometimes we have to be a little selfish to be better people – partners,
parents, practitioners, friends.
Please do not construct an extreme wellbeing plan in the first instance that
is unsustainable and will not work. Caffeine, chocolate, salt, comfort eating,
alcohol, rest days, lazy days all should be included in any wellbeing plan in
MODERATION.
Essential Components of a Wellbeing Plan:
DIET: what we eat fuels our body. Food we consume impacts our energy
levels, mood, sleep and even our brains. Many people in health who work
shifts, weekends and changing rosters have unique needs when it comes to
diet as a result. Unfortunately too many staff in critical care use sugar and
caffeine for short bursts of energy and then alcohol to assist with ‘coming
down’ and rest. Eating foods that sustain energy is important. Time
constraints can also impact what we eat so bringing healthy food options
from home will dramatically change the way we eat at work. Nuts, fruit and
meals that can be eaten in small bites at a time can be important as people
quickly grab mouthfuls of food in between important jobs. Carry a bottle
of water with you or leave it at the station at all times as hydration
dramatically impacts how we feel and our cravings.
http://www.dietitians.ca/Your-Health/Nutrition-A-Z/Healthy-Eating/10-
Nutrition-Tips-for-Shift-Workers.aspx
Neif-Sztramko et al 2014 Health-related interventions among night shift
workers: a critical review of the literature Journal of Occupational and
Environmental Medicine40 (6): 543-556
EXERCISE: Exercise does not need to be a sport or related to a physical
challenge. You should not be exercising for the ‘perfect body’ or for
punishment for what you ate. Exercise for wellbeing should be something
you really enjoy and look forward to rather than a chore. If you respond by
saying you don’t enjoy any exercise you have not tried enough options.
Walking the dog, swimming, running around with the kids, cycling, yoga,
karate, boxing, dancing, acrobatics the choice today is limitless. This time
should feel like a wonderful indulgence. Energy creates energy. So when
you are feeling most lethargic try and move. Exercise will increase your
capacity to cope with life, improve your overall health and give you some
time to help your brain unwind. Using a pedometer to regulate how much
you move is also helpful. We should all be aiming for 10 000 steps a day
(7kms/4.5miles). Sometimes this is difficult to judge without using a
prompt. If you haven’t met this goal a brisk walk around the block can help.
SLEEP: We all know sleep is important however having a regular sleep
routine is very challenging when you work shifts. Try to maintain a routine.
Be mindful of what you do as you prepare to sleep. Be careful what you
consume. Importantly be mindful to stay off screens and social media in the
30 minutes before bed. Try instead to read, do meditation or mindfulness,
have a relaxing shower all tasks that tell your body it is time to turnoff and
sleep.
https://sleepfoundation.org/ask-the-expert/electronics-the-bedroom
BREATHING: The way we breathe can impact energy levels, stress and
relaxation reactions and the state of our body. Next time you feel anxiety
rising or energy depleting become aware of your breath.
Van Diest et al (2014) Inhalation/Exhalation Ration Modulates the Effect of
Slow Breathing on Heart Rate Variability and Relaxation. Applied
Psychophysiology and Biofeedback, 39(3-4) p171-180
http://www.forbes.com/sites/daviddisalvo/2013/05/14/breathing-and-your-
brain-five-reasons-to-grab-the-controls/#3538a18b52aa
BENEFITS OF STILLNESS AND QUIET: Each day try to find an
activity that allows your mind to be still. This can happen while you are
exercising, in the shower or as part of a disciplined mindfulness or
meditation practice. Become more mindful about what you are doing, how
your body is reacting, your behaviours related to this and what you want to
achieve. This can be a very powerful practice.
Morgan et al (2014) Health Care Workers’ Experiences of Mindfulness
Training: a Qualitative Review , Mindfulness Vol.6(4), pp.744-758
QUALITY TIME: Be mindful of how you spend your downtime.
Television, screens and even our beloved social media time can be an
incredible time waster with little benefits for our wellbeing. Try to be
outdoors and in nature regularly. Surround yourself with good people. If
you are moving a lot because of training and career needs take the time to
keep in touch with others and find one or two quality people every time you
move and invest in these friendships as a priority.
FIND YOUR THING/S: Sometimes we have to fight for our own
wellbeing and health. It rarely comes naturally. Prioritise yourself. Work
hard at being well. Sanction time and do not let anything disrupt it. Your
body and your mind will thank you for it, as will those that love you and
your patients and colleagues.

EXAMPLE OF A WELLBEING PLAN– Liz Crowe (this is not a

recommendation based on science or nutrition, nor is it advice, it is just an
example)
Diet – I like to eat lots of protein, salad and vegetables, I don’t like hot
drinks so consume lots of water. I have to eat breakfast in the car most
mornings so I eat toast with protein – ham, egg, sausage etc. This fills me
up and can be eaten on the run. I take nuts and an apple to snack on, if I
have trained in the gym I will put peanut butter on my apple for extra
energy. I take a sandwich for lunch full of salad, vegetables and a protein, I
can eat it one bite at a time, doesn’t need heating, doesn’t spoil and can be
re-wrapped as required. I try not to eat chocolates and biscuits that come
into the unit but on the days I do I don’t feel guilty about it I see it as a treat.
I drink loads of water and bring a bottle in with me each day and keep it
available.
Exercise- my goal is to walk 10 kms/6.2miles each day. I love walking and
it is my time to think. Walking is also my outdoor, be present with nature,
look at the sky remember how insignificant I am time. I try to have one
walk on my own with music and the dog and one with either my husband or
one of my teenage sons. They whine a lot for the first 5 minutes and then
we both really enjoy it. I try to do a dance class once a week (dependent on
my children’s sporting schedule) because dancing makes me very happy!! I
try to get to the gym twice a week to do weights and strength training. I see
a personal trainer once a week. Yes this costs money but I don’t drink coffee
or wine so I figure this is my one indulgence. I always box with him which
is a lovely way to punch out frustrations, anger, concerns and feel really
tough at the same time. I find it works wonders for my stress. I used to
cycle a lot but it became too time consuming though I hope to return to it
one day. I also love swimming but it is also time consuming and means I
have to wash my hair….
If I want to catch up with friends rather than just go somewhere and eat I
usually organise a long walk followed by breakfast or a meal. That way you
have exercised outside and been with a friend!
Screens: I watch little to no television during the week. I try to only be on
social media when I am on the train on the way to and from work. I
schedule my study time so that it is sanctioned and controlled.
Sleep: I am not a great sleeper and I have little time to sleep due to
parenting life, study and work. I try to ensure quality sleep and have a strict
routine going to bed each night. I shower just before bed, have a big glass
of water and read a fictional novel for 15 minutes or so to turn my brain off
from the busyness of the day. I also try to organise a nap on days off
whenever possible.
MY THING: Music and movement is absolutely my thing. When I am sad
or low in energy music is my way to cathartically cry, reinvigorate myself,
be foolish and exercise. Humour and finding the joy in life is also
exceptionally important to my wellbeing. I have a very dark and sick sense
of humour that erupts at the most inappropriate times. I surround myself
with wonderful people at work and in my personal life who I can laugh and
cry with and who I genuinely enjoy their company. My children are also a
major source of wellbeing because I love them to bits and because they pull
me back to life after a tragic or sad day by their own needs and demands.
vb
Liz
@lizcrowe2

RECOMMENDED READING:
The Essence of Health: the Seven Pillars of Wellbeing by Dr Craig Hassed
2008
Chapter 2- Written by Natalie May

ATTITUDE OF GRATITUDE – SHOWING SOME LOVE IN THE

ED

There are many things I do which are stereotypically “British”:

drinking tea, apologising instinctively (especially when it isn’t my fault),
engaging in our national sport (queueing), becoming intensely irritated
when other people fail to comply with the [unwritten] rules of our national
sport (aka queue jumping) and, apparently, struggling to express positive
perceptions about people.
 I know this isn’t just me; there is an intrinsic awkwardness to saying
positive things to people (look, for example, how much has been written
about giving negative feedback – there’s an imbalance with positive
feedback because we often don’t even know where to start). BUT: when we
do say thank you or express our gratitude – and mean it – it can have a
tremendously positive effect.
 The reason I include Katrin’s response is because she was genuinely
shocked that such an event was worth talking about – that it was so rare as
to be notable. This conversation occurred a little while back, but I think
about it regularly. Do you thank your colleagues as a matter of routine? If
not, why not?

Why is thanking people important?

I don’t know if you’ve read the papers lately, but it seems that in the
UK Emergency Medicine is having a slightly difficult time (to put it in
rather British terms). That said, I still absolutely love my job and couldn’t
envisage myself working in any other specialty.
 But I have to admit, being told by a newsreader almost every day
while I get ready for work that it’s going to be horribly stressful and utterly
rubbish when I get there doesn’t really put me in a positive frame of mind.
What keeps me going when I do arrive is continually witnessing how
incredibly hardworking and committed my colleagues – in medicine,
nursing, and all our non-clinical supporting staff – are; I feel incredibly
privileged to be a part of the ED team and it is one of my absolute favourite
things about our specialty. But maybe I don’t tell them enough.
Energy and enthusiasm aren’t limitless and we all feel the pressure at
times. Not too long ago, while I was having a particularly difficult time,
someone said something non-specific but overwhelmingly positive about
me. The effect on my morale was incredible. The bottom line is that we can
make people feel like this every day. To quote this paper,
“job satisfaction and organizational commitment are closely linked,
and are both very important for general organisational success.”
We work hard and sometimes the work is hard, both physically and
emotionally. We see terrible things and do our best to relieve pain and
suffering. It doesn’t always work and that can leave us feeling demoralised.
So we really need this stuff; the perception that we are valued by our peers
and seniors is incredibly important to our professional identity and it is
reasonably well-evidenced that happy workers are productive and more
healthy

How can we make it meaningful?

My final year of medical school involved an 8-week paediatric (of
course!) elective in Uganda. I worked in a small rural hospital where the
nurses tirelessly translated our medical questions into the local dialect and
the [often nonsensical] answers back into English. At the end of every shift
we would have a short but meaningful exchange with the nursing staff in
Lukonjo:
Doctor/Medical student: “Wasinja erikola” (Thank you for your work)
Nurse: “Wasinja erisema” (Thank you for appreciating me)
 My written Lukonjo isn’t the best, so I may have spelled these phrases
wrong, but they were delivered without fail at the end of every shift, with
eye contact and a smile. I remember it very clearly along with the thought
that it was so odd that we didn’t routinely thank people in the UK.
The phrase “thank you for your work” is a little clunky in English so I
tend to thank my colleagues for their help as I finish a shift and when my
sincere thanks is reciprocated it brings a sense of achievement and value
that lasts longer than most clinical achievements. Make eye contact, be
specific if you want to have real impact (“thanks for your help with that
patient – you did a great job today”) and make it a habit. Once you get
started it gets easier, I promise. Let’s show those Europeans that expressions
of gratitude and appreciation in the workplace are the rule, not the
exception.
And don’t forget, patients get better care from happy staff. And
chocolate helps too.
Agree with me? Why not pledge?
If you agree with the above, why not make a pledge for NHS Change
Day? You can make your own pledge here or join Carmen Soto‘s here – or
any of the other pledges about saying thanks…

vb
Natalie May
Chapter 3- Written by Liz Crowe

WHERE’S THE LOVE IN CRITICAL CARE?

We are into the second month of a new year. Many of us in critical

care may have made a resolve to ‘take better care of ourselves this year’.
With promises of more exercise and less alcohol and caffeine. So how are
those resolutions going?
What if I proposed that another way we can take care of ourselves and
our patients better was through the use of self compassion, compassion and
love? Too ‘soft’ for critical care? Not based on research and evidence?
What if I could prove t you with science and research that love may be the
answer…… Would you take the time to think it over?
If we look at any critical care system there are several components
that are required to drive quality, safety and ultimately success. The
greatest driver of success is ultimately the staff. Staff who feel safe, valued
and supported will thrive. Staff who have a passion and commitment for the
job will be more creative, committed and demonstrate a stronger loyalty to
the organisation increasing practice wisdom and skill base. All of these
components build successful critical care teams and improve safety and
quality of care for patients and their families.
Critical care attracts staff who want challenging work that tests their
intellect, a dynamic environment and a competitive drive. So seriously …
LOVE? Does love have any place in the critical care environment? Should
love even be mentioned in the same sentence as Leadership, intellectual
endeavour or Patient Care? Medicine is embedded in a culture of evidence
and research. The science of love will demonstrate how it is a powerful
protective factor to wellbeing, increases retention rates and recruitment
possibilities, build pathways to creativity and adaptability and shapes strong
leaders and effective teams.
Watch the video from SMACCDub below and the read on to learn
more about love and critical care https://vimeo.com/188765724.
 OUR RELATIONSHIP WITH WORK
Human beings are hard wired for connection and so we naturally bond
with others. Yet relationships remain a tricky business. We negotiate our
personal relationships all the time with partners, children, siblings, friends
and colleagues. Relationships are difficult to sustain and for most of us one
of the longest and most successful relationships we will have in our lifetime
is our long term relationship we have with our work in critical care.
Like any real relationship our relationship with critical care will be
cyclical and have periods of ups and downs. It will hopefully start with
great enthusiasm and passion and then overtime it will become habitual and
familiar. There will be times when we are still passionate and enthused
about work and times when we are bored, disillusioned and may even think
of straying to something else.
There is a lot of discussion about the need for work/life balance which
is essentially setting us all up for failure. We spend the majority of our time
at work, studying and researching for work or thinking about work
relationships. Therefore particularly when you consider the shift work of
critical care there is NO such thing as work/life balance. It is an annoying to
assume that if work is a major part of your life it is a bad thing. Achieving
great harmony with your private and professional life is achievable if you
are happy at work. There is no need to only be happy on days off. If days
off are the only time you appreciate life you need to review what you are
doing for a living, or at least who you are working for. If work brings
meaning, pride, community and a sense of purpose than you can be happy
at work MOST of the time. You can proudly Love your work and achieve
work/life HARMONY.
Our work relationship life any real relationships evolves over time.
There will be times when you don’t love work, this is a time for pause and
reflection. There will be times when our relationship with work will be
difficult and be challenging, and if you love it enough and the factors you
love about remain unobstructed your relationship with work will survive.
On the whole, for the majority of us, critical care is much more than
resuscitation and hero work. It is the daily grind of caring for the
vulnerable, the agitated, the elderly and the unglamorous. Days that may
seem mundane to us will never be mundane to the individual patients and
their families who found themselves in our care.
No love and passion is sustained consistently over the course of time
– in any relationship (sorry folks). We have to expect there will be times at
work when other specialities look more exciting and enticing. When the
thought of something ‘new’ will seem better. However, there are few
specialities that offer the diversity and action of critical care. Fight to
maintain that passion.
So love is not always hot and spicy. There are times when routine is
okay. When work is quiet, or at least sane, use these times to consolidate
skills and connect in a meaningful way with our colleagues, to ask people
how they are and to focus on education and quality
 BE A LOVE AMBASSADOR

Science demonstrates that people and teams thrive in an environment

where they feel valued, appreciated and have the opportunity to grow and
be innovative. Look at what companies such as Google do for their
employees. Staff Specialists and team leaders set the tone for work each
day. The literature on emotional contagion demonstrates that negativity
spreads through a team faster than passive smoking or a viral infection.
Who do you want to be in the team? How do you want your patients and
colleagues to remember you at the end of a shift. Be a LOVE
AMBASADOR. The person who is safe to confide it. The person that
grows others into great clinicians and leaders. We should all be trying to
leave the next person bigger and better than who we are. Share love with a
big open heart. Be fun, caring, compassionate. The more you give the more
life will be meaningful. Compassion is a protective factor against
BURNOUT. It takes a lot of emotion to contain and control feelings.
Giving freely is liberating and so meaningful.
In Edmondson’s fantastic book ‘Teaming’ (2014) she talks about the
concept that rarely do people belong to one team today, that we are teaming
all the time. The team on the floor, the team in a resus, the team with other
subspecialties. Each time we ‘team’ we have to clearly designate leadership,
roles and connections in order to keep excelling.
 So often we talk about professional boundaries and ways to ‘protect’
ourselves from caring too much about patients. While we should never
become friends or connections with patients on social media there are time
where human touch and visible human connection are not only warranted
…it is the greatest and most powerful medicine of all. We need to teach
people how to connect and understand others better. So many people in
critical care are exceptionally academically intelligent. All of us need to
strive to build our emotional intelligence so that we are stronger
communicators, greater colleagues and leaders with skills rather than just
seniority.

DOES LOVE HAVE A PLACE WITH LEADERSHIP?

Great leaders don’t lead through aggressive, fear or intimidation.
Look at the quiet strength and ability to create change through the quiet
love of Mandela, Mother Teresa and Gandhi. The greatest leaders in critical
care are loved and respected by staff for being personable, approachable,
strong, clear in their communication, had a sense of fun and most
importantly protected, enabled and empowered their staff at all times. They
did NOT have to always be the hero, the smartest or the scariest.
Great leaders create psychological safety. Great leaders create a
climate of trust and intimacy that makes individuals and the team feel
emotionally and physically more comfortable and allow for robust
conversations and disagreement that does not lead to lasting conflict nor
does it impact the team. Great leaders protect their staff from the day to day
grind as best they can. They let their staff know that any mistake that is
made is human and falls to the system, not the individual. Great leaders
love their team, apologise quickly and are consistent in their behaviour.
Our critical care team should feel like a family – with all its culture,
eccentricities and love.

LOVE GROWS YOUR BRAIN

 When people feel loved and supported their brain capacity grows. It is
why there is more and more emphasis on attachment theory not only
between a parent and a child but how early attachment history can impact
relationships in the future, including the way we react and engage at work.
We will never love every single individual we work with – patients or
colleagues. We do need to respect and listen to them anyway. Try and find a
work spouse, the person in the team that you can safely unpack the day,
thrash out problems with and ask “am I wrong?” and know they will answer
truthfully. Individuals can be more intelligent, more creative and more
innovative when they have less stress and feel safe.
Love builds innovation and creativity. As critical care becomes more
governed by fiscal constraints and lean thinking and hospitals are run more
like businesses and less like hospitals we will need critical care staff to use
all their brain power to solve new problems with new solutions. This can
only be achieved in an environment of safety.

LOVE AND PATIENTS

We see people in the most vulnerable, frightening and horrific
moments of their lives. We will never have the capacity to cure each person
we see of every physical and psychological ailment they present with. We
do have the opportunity to make a difference in their day through
connection. Love , respect, integrity and compassion are gifts we can give
to our patients that will never impact budgets or hugely change length of
stay. In fact it is proven that when patients feel heard their length of stay is
shorter! Start every engagement with patients with a level of compassion
and openness, build rapport quickly. You will find that if you are kind to
your patients, on the whole, people will be more forgiving of wait times,
error, several attempts to get a cannula in, or any other inconvenience either
you or the system put them through. Why? Because they will feel valued
Remember that for a very long time medicine was more about caring
for people, connection and concern than it was about technology and
science.
LOVE OF SELF
Even if you give 150% every day, even if you are and kind and skilled
and clever, there will be days when this job sucks. When it is all frustration,
tragedy, sadness and pain. These are the days when love is most important.
When that love has to be kindness and compassion to self. None of us is
perfect. There are days when we may need to be a little more careful with
ourselves, a little more forgiving. On these days share your vulnerability
with your team and maybe if appropriate your patients. Let them know that
life is tougher than usual so that people can cut you some slack or bond
with you over the injustice of life. Nurture yourself like you would a best
friend, without the ruminations and self torture. Seek out those who love
and know you most. Know that this time to will pass
Remember what brought you to this work. Every day fight to find
your ‘IKIGAI’ and you will live a blessed life

vb

Liz Crowe
Chapter 4- Written by Janos Baombe

TOUGH TIMES IN THE EMERGENCY DEPARTMENT

Is your ED seeing an unprecedented number of patients lately?

Do you feel like you are under excessive pressure because of this?
Do you recently feel low as a result?
Maybe you’ve even thought that EM is not for you anymore and
considered leaving your specialty (SACRILEGE!) [Ed – it’s ok, we all
have days like that]
Try the following tips to boost your morale and that of your team, even
in these tough times.
Disclaimer: the following tips are not necessarily based on evidence.
These are things I have picked up during my short time as a humble
emergency physician in a large, busy city centre ED. I hope you might find
them useful and maybe even select something to take home with you…

Practice gratitude
In this fast-paced crazy word we often forget to use a very simple way
of expressing our appreciation: saying thank you. Say it ad nauseam, feel
free to add “so much” and combine it with the recipient’s first name if
possible. This last point can be tricky if you work in a big centre with
hundreds of professionals, like I do. It is difficult to remember everyone’s
first name (let alone how to pronounce it) and I have to use all sorts of
tricks to try to decipher first names on ID badges hanging on lanyards. But
practicalities aside, would you not raise your sore, heavy head from writing
your notes if someone from the team said to you: “thank you so much for
coming down to the ED to help with this challenging case, Janos”? This
builds good rapport with your multi-discplinary team, builds resilience and
let’s be honest, it is pure courtesy you will have learned from your mama!
Help others
You are more likely to get help from others if you help out too. People
will remember a small favour you did for them (like helping with a difficult
cannulation or taking those notes to reception on your way to the coffee
room) when you ask for another one in return. Cliff Reid talks about this
(amongst other things) in his excellent SMACC talk “Making Things
Happen”. If you have not seen/listened to this talk yet, I suggest you do so.
 There is no fixed currency exchange here: you are likely to get a
bigger favour back than the original one. It is simple psychology but it’s
also good for your soul!
Practice smiling and say good morning
It is so much more pleasant to work with someone who smiles than
someone with a grumpy face! It is well-known that smiling and a good
mood are contagious. I like to say a loud “good morning!” as I walk
through the department before I reach my office. Do not forget to include
non-clinical staff into this habit. Our domestic staff, for example, always
seem surprised when I walk in with a smile and loudly greet them! They are
part of the team but I suspect they often feel forgotten and undervalued in
the big hierarchy of our healthcare system. Associate your smile with a bit
of good humour and you will be the star everyone wants to work with.
Patients will also appreciate and remember that compassionate smiling face
(caveat here: use it appropriately), staff are more likely to help you out with
unpopular tasks and you will boost your own morale. If you don’t feel like
smiling, try this (as recommended by EM legend Steve Jones): hold a pen
or pencil between your teeth for two minutes. You’ll find smiling much
more natural afterwards. Works best if there are a group of you doing it at
once!
If you struggle to stay positive, try getting into the habit of reflecting
on Three Good Things each day (more info from Rob Orman at ERCast
here).
Share your mental model
This is discussed and taught at lengths at various resuscitation courses
nowadays. Prepare your resuscitation room, prepare your equipment, run
through the options before your critically ill patient arrives. It’s not rocket
science: the patient will get the care they need if you have planned ahead
whereas unprepared teams result in poorer outcome both for the patient and
the team. Remember the old adage “failing to plan is planning to fail”?
This however works for non-critically ill/injured patients too, so make
sure you verbalise your plan even outside your resus room. Most of the
complaints we receive are results of poor or nonexistent communication
between staff and patients. People talk about shared decision-making but I
would like to think this is simple good communication. “Mr Brown, I am
planning to perform a chest x-ray with your consent and if this shows signs
of an infection, we might well need to admit you into hospital”. This might
sound excessive to some but I would argue that it is simply spelling out a
potentially complex process to a patient who might not be familiar with
your plan/the system and by doing so we can cover all aspects of shared
decision making.
Use alternative ways of asking
Difficult referrals occur on a daily basis in our specialty and are a
source of frustration for junior and senior staff alike. There is nothing more
frustrating than “having to sell that referral” and this can occur for a variety
of reasons. The most common reason for conflicts, however, is that the
mental model I talked about above is not shared in an effective manner so
that the colleague taking your referral does not necessarily share or
understand your perceived need for the admission.
Most referrals nowadays happen via phone or another similar
communication device making that valuable face-to-face contact disappear.
The emphasis is on the verbal component of the process and words are
worth gold here. Instead of shyly saying “I would like to refer Mr Brown
for admission because of a fall”, try to expand on your reasons for
referral/request for admission. Try something like, “I was hoping you could
review Mr Brown because of a recent fall. He lives alone at home, has poor
mobility and visual impairment due to cataracts. I am worried that he will
not be able to cope at home alone and is therefore at risks of further falls. I
think he would benefit from the excellent service your team provides”.
Flattering but more likely to be effective…
Cliff Reid discusses this too in the above-mentioned talk.
Practice emotional intelligence
My colleague Rick Body recently spoke about this at the last RCEM
conference in Liverpool. Emotional intelligence is an important concept for
emergency physicians and is often overlooked or forgotten. It is the ability
to control your emotions so you can be ‘hard’ and ‘objective’ in challenging
cases, while later allowing yourself to express your emotions when it’s
appropriate to do so – e.g. when talking to a patient’s family after a death.
We are all different and react to emotions differently. There are people who
tend to make jokes, while others are able to just carry on after ending a
resuscitation, for example.
It isn’t that we don’t feel emotions but instead this is probably just our
‘barrier’, our way of shielding ourselves from the storm of our emotions.
Rarely do we allow ourselves to show outwardly emotion as super-docs but
there’s no doubt that our thoughts still continue for a short while after a
difficult case. After discontinuing CPR, it’s very likely that some people are
still thinking and processing, carrying emotional luggage that needs to be
dealt with rather than suppressed. We are humans, not machines. Having
emotions is characteristic of mankind: do not try to be a machine! So make
an effort to discuss the clinical aspects of difficult cases during your debrief
but also try to cover the emotions felt by your staff as well.
 If you’re interested in knowing more about debrief, we recommend
this excellent podcast at ERCast featuring our very own Ashley Liebig.
In summary
We do know that it is essential that we do not lose our cool during the
management of a major incident or when leading a resuscitation team. This
is evident.
 I would however argue that it is equally important that we do not lose
our cool even during our mundane tasks. I mean it is so much easier to be
nice and pleasant than being a grumpy face. Just be nice and cool. In that
order! Try it…

Be good!
Your humble servant Janos
Chapter 5- Written by Ross Fisher

THINGS THAT SCARE ME

This blog post explains the background to my talk in Dublin at the

SMACC conference. This talk, entitled ‘Things that scare me’ is a
waypoint on a journey that I’ve personally experienced. I believe it’s a
journey that many of us have either taken or are on and I hope that
this talk will help my friends and colleagues navigate that path. Please
visit the SMACC website to watch the original video from SMACC and
visit BroomeDocs to listen to the background story explaining my
personal journey which I sincerely hope may help other who find
themselves in challenging circumstances.
Lessons Hard Learned: What Scared Ross Fisher?
In our clinical lives there are situations that challenge us, situations
that cause us to feel stress and situations that actually scare us. It is good to
recognise the difference and, challenging as it might be, it is good to accept
that there are things that scare us. Challenges, situations, problems that
bring us to that place where we are truly afraid. How we are affected by
these situations is of grave importance. How we manage these situations is
difficult but, in a non expert but experiential way, I would like to offer some
thoughts on the matter. What scares you?
 Things that scare me as a paediatric surgeon probably come as no
great surprise. Tiny, premature neonates who require emergency surgery for
perforated necrotising enterocolitis are a major challenge. They are a
challenge to everyone involved not the least because they appear to exist in
a physiological place completely different from the rest of humanity. They
can have a pH of 6 point something and still be alive. They can have a
biochemical picture that frankly terrifies anaesthetists with little experience
of such infants. And they can have a coagulation picture that simply doesn’t
make sense. They can just bleed. And when they do, that frightens me.
As surgeons we like to believe that we know what we are doing.
Torrential bleeding during the resection of a massive tumour is where things
are can wrong. Often, all that can be done is a major clamp placed rapidly
across everything to deliver and resect the tumour. At that point, finding
things not as they should be, frightens most surgeons.
Our careers are precious. They are the pinnacle of years, often
decades of training. They define us. They are what sustains us, what
provides our livelihoods and often those dependent upon us. Without our
careers our lives would look completely different and many of us are unable
to conceive of life without them. When our career is significantly
threatened, particularly by forces of our direct control, that scares us.
And yet the challenge of this piece is to ask you, right now, to
consider precisely: what in your line of work scares you? It is likely to be
different from the things that scare me, as fear is deeply personal. My
challenge to you is to see that fear, recognise that fear and name it.

Specify It. Right Now. See It Right In Front Of You. What Scares You?
I’m here to tell you that it is ok. It is ok to be scared. It’s okay to be
scared because being scared is actually a reaction to something that
represents a significant threat to you. It is a challenge more than we think
we can handle. Being scared is a recognition that you perceive a problem, a
limit to your skills or a shortfall in your ability, a place where you are
deeply comfortable being you. And that situation, in itself, is ok.
Researching this, I am aware of all sorts of amazing resources
available in the #FOAMed world on stress. There are podcasts, workshops,
blogposts and self help groups all dealing with stress and its management. I
cannot recommend them highly enough for those of us who work in
stressful situations. To be perfectly honest, the things my colleagues in
Emergency Medicine, prehospital and critical care do every day would give
me an incredible level of stress, let alone specific situations. And that’s an
important fact, stress and fear are very individual. Most of us have learned
strategies for dealing with stress. More than this, as Chris Hicks pointed out
in his talk at Blood and Sand (2015) last year, there probably is an optimal
level of stress for excellent performance where we are sufficiently
stimulated but in control to deliver effectively. That is where training helps
us to recognise the effects of stress, develop strategies to manage it and
train for success.

I Want To Talk About FEAR, When We Are Way Into The Red Zone.
Fear is complex, but basically it all happens in the thalamus.
Whatever the sensory input of our fear is, that one, right now, the one you
are trying to push out of your mind, the sensory input goes to the thalamus.
The thalamus sends out information in two directions. The fastest is through
the amygdala where our rapid response is activated via the hypothalamus to
immediately respond, response without thinking. It’s all about the sabre
toothed tiger thing. No time to think, just react. The hypothalamus fires off
the Sympathetic Nervous System which brings about readiness for flight or
flight. All of which is good for a fight but not necessarily so good for
dealing with an acute clinical emergency.
This massive stimulation due to fear affects how we physically
perform: fine motor tasks become almost impossible; the tachycardia and
hypertension give us that pounding headache; crazily our visual acuity may
actually be increased but always at the compromise of peripheral vision, all
we can focus on is the specific problem; while activity outwith our field of
vision is obscured; we become unable to take in task relevant cues either
verbally or visually; our working memory is blunted; our cognitive
processes become blurred; we overreact to perceived challenges and threats;
we extrapolate as part of the longer view of the threat and it leaves us
unable to trust other people or their decisions or even to trust ourselves.
The effect of our fear on others is also real; it is contagious. As social
animals we perceive and react subconsciously to other people’s emotions.
Fear within a team environment means people are no longer predictable,
normal routines and practices don’t work, reactions and decisions vary
particularly when the team member expressing fear is a senior. The fear
spreads and the group exhibits the same fear often with no understanding of
the process that has brought them to this. Fear spreads amongst a group.
The evidence is clear from studies that poorer outcomes occur not due of
lack of knowledge or of training but due to poor communication and
teamwork precipitated by fear.
Fear is a big problem. We all have things we fear and they make us
and the groups we work within behave differently.
Fear ”lives” in the amygdala. It is hard wired because learning to fear
predators and threat slowly and gradually confers little evolutionary
advantage If you damage the amygdala in rats they will just walk up to a cat
with no “fear” and get killed. Clearly the medical things we are afraid of are
not hard wired. They present threat due to many different reasons- the
majority of which are due to conditioning. The reasons for our fear are
complex. They involve all sorts of things from simple learning, negative
reinforcement, reflection, exposure, chance, gossip, hearsay, extrapolation
and even fantasy.
If fear lives in the amygdala, the moderation of that fear comes from
the hippocampus. It appears to be the source of conscious recollection.It
advises us that despite the initial shock things weren’t as bad as you
originally perceived and you can tone down the fear response. This is how
we learn not to be afraid. A situation that terrified us in the past and no long
does so is due to the effect of the hippocampus.

So, What Can Be Done To Manage Fear?

Now, I really am no expert, merely someone who has been afraid. I’m
not here offering complex answers or a particular training course but
principally a single personal reflection. Fear is real but there are things we
can all do to mediate its effects. Please make sure you look after yourself in
whatever way works best for you. I think the most important thing we do
regarding fear is to acknowledge it, name it, and accept that it exists. It then
becomes something tangible that we can begin to deal with it. It would be
valuable right now for those reading this to name that fear.
 In considering whether you can name this fear it is important to
recognise that doing so is not a sign of weakness. It is not a sign of poor
training. It does not mark you down as a person who is untrustworthy or
lacking ability. Rather, it marks you as honest, as real.
Now consider how you would feel if a colleague shared with you their
fear. Would you see them as weak? Would you consider them now to be
poorly trained? Of course not. Now consider how you would react to that
person. Would you walk past them, ignore them or criticise them? No, your
response would be to stand with them. When you are experiencing fear, try
not to ruminate and be judgemental of yourself. Be curious about the fear,
explore it without judgement or criticism.
 And that simple step is, I believe, how we start to counter fear. Of
course there are more complex strategies and protocols and workshops to
deal with this but the first thing about fear is recognising it in ourselves and
in others. It is about accepting the humanity of what we do, the reality and
the brutality of what we do, that it is ok to be afraid and that our colleagues
understand and support it because they too have in their own place been
afraid. We don’t criticise it, mock it or even ask what it is, we just recognise
it. And in that recognition fear loses so much of its power over us.
Those who stand with us when we are afraid and offer their
confidence in us where we have little in ourselves are significant people to
have around.. The catastrophising voices in our heads can be replaced by
the voices of those who stand with us. The voices we then hear when we are
afraid are our chiefs, our heroes, our peers and our colleagues and our
friends. Sometimes they are there in person, sometimes just in our head but
those are the voices we should learn to listen to when we are afraid.
Please take a moment now to consider how you manage what has
happened in reading this blogpost or listen to the podcast. Your mental
wellbeing is fundamental and caring for that is essential. We each have our
own approaches. In the same way we care for patients it is important that
we care for ourselves. If this has raised difficult issues please take time to
speak with someone you value recognising that we all have issues of fear in
our lives. It is a sign of insight to recognise fear and not consider it
weakness. You and your wellbeing are so important, please look after
yourself.
Fear is real. It affects how we perform. But if we accept it and stand
with each other, it will change.
vb
Ross Fisher
Chapter 6- Written by Janos Baombe

HOW TO LOOK AFTER YOUR OWN MENTAL

HEALTH

DISCLAIMER: the below tips are based on no evidence whatsoever but are
some pearls I have picked up during my relatively short career in
emergency medicine. I however hope you will enjoy the read, give some
thought to the content and maybe even take something home from it.
Accept who you are
We do need role models to shape our professional career progression.
However, it is worth remembering that every single one of us is unique: we need
first to understand this and more importantly accept it. Ever heard of the Myers-
Briggs indicator? In short, this attempts to make the theory of psychological
types described by C. G. Jung understandable and useful in people’s lives. So,
know yourself, know your strengths and weaknesses, accept them and learn how
to work with them and others around you: take the questionnaire!

Take a break
Allocate yourself some time to rest both mentally and physically on a
regular basis. Our noble profession is a very fast-paced and exhausting one: we
often forget to ensure that we disconnect from what has become our daily work
routine. Your mind and body need some rest so make sure you book your
holidays in advance. Use the Tarzan principle: swing from one holiday to
another like the king of the jungle swings from one vine to another. Do not spare
money when booking leave, be generous with yourself, treat yourself: it is a
special moment for YOU. Switch off your work emails to avoid to be constantly
reminded of the buzz and stress related to your clinical work

Keep in touch
Time flies by with the speed at which our job goes on but life does not
wait. Make sure you keep in touch with your family and friends, even if it is only
through via phone or social media. Do your best to actually meet them face-to-
face for a dinner, cinema or a few days together to remember the good old days.
When was the last time you sat down with your parents and told them about
what’s going on with your life both in and outside of work?

Talk about your feelings

Even emergency physicians are humans (well most of us are anyway!).
There is no shame in having emotions inside or outside work. We fall in love, we
get married, we split, we are happy about a clinical case and another will bring
us down. It is much easier to share emotions than carrying them around alone,
hence the idea of debriefs after an unsuccessful cardiac arrest resuscitation or a
drink with a dear friend after you split up with your last partner

Eat well
Try and promote you own health by eating regularly and by incorporating
regular meal breaks. This undoubtedly might be difficult due to the shift patterns
we often work in. Keep away from heavy, spicy foods to avoid that dip in the
middle of your shift following your meal break. Equally the temptation is big to
stuff yourself with all the cakes and sweets often left around on the shopfloor.
Some carbohydrates for your brain function is good (and endorphin release
makes you happy) but too many is bad for your hip (and morale). I am no good
cook but I would suggest that packed lunch is better than canteen carb loading
(though I remember that canteen we had when I used to work in Paris…)

Drink sensibly
This links in somewhat with the above. Turning up in work the morning
following a bottle of Chardonnay with your mates is likely to make you slow,
grumpy, frustrated at your own performance. This often is contagious to staff
around you and patients will certainly not appreciate it. I would argue it is
actually unprofessional and therefore bad for you (especially if this results in a
clinical error or disciplinary procedure)

Get some sleep

This again sounds very obvious but emergency physicians are notoriously
very bad at this. Sleep can be very elusive due to our shift pattern work, social
and family life. @_NMay provided some top tips on how to maximise your sleep
in a recent StEmlyns blog with some links supporting the theory that lack of
sleep if bad for you both as a person or a doc

Keep active
“Mens sana in corpore sano”
 We keep spending our time telling our patients what they should and what
they should not do. I am personally very pleased to see that most of the
emergency medicine conferences have now embraced the idea to organise
jogging sessions before/after the academic sessions. It is not only health
promotion (@_NMay talked about this at the last RCEM conference) but also an
opportunity for social networking. See the pics on the now world-renowned
SMACC or EuSEM runs (#SMACCRun, #EuSEMRun on Twitter) if you do not
believe me. I started training for the jog planned in SMACCDub so will you be
there?
(Thank you to @_NMay, @umanamd and @aLittleMedic for allowing me
to use this SMACC Chicago jog pic: fantastic memories!)
Alternatives to consider would be yoga, relaxation classes, book clubs or
mindfulness: anything that allows you to escape the daily grind and more
importantly anything you enjoy doing outside of work!

Ask for help

Again, there is no shame in doing this. It might be a difficult case you want
to discuss with a senior (and why not a junior?). Create a culture of asking at
your workplace, find a mentor or friend you can go to when need is. I still today
go back to my previous educational supervisor and ask for opinion or help: it had
become natural to me to knock on his door and say “I wondered if we could
discuss something”. If you are a senior, ask juniors about their thoughts: make
the traffic both ways.
Do not hesitate to consult specialist help if you feel the need to.Some
places have specialised clinical support groups to help clinicians in difficulty.
Involve and learn from teams and tribes outside of yours: it is the concept
of reciprocal illumination Victoria Brazil talks about often.
 Asking for help might also link in with the issue around emotions I
mentioned earlier. Is life simply not easier if you share your problems?

Do A&A (amazing & awesome) sessions

@EMManchester talked about this recently. We spend an awful amount of
time being told off for things that went badly at work. Do we actually spend time
to congratulate ourselves on things that went well? This does not need to be a
success in managing a complex clinical case: it could be something as simple as
meeting a pleasant patient, meeting a colleague on the corridor you have not seen
for a while or simply the fact they served your favourite meal at the canteen
today. So when you leave work today, list three good things that happened to
you and…enjoy the smile on your face!

And a final (cheeky) word of wisdom…

 I hope everyone will be able to take home at least one or two tips and use
as part of a long-term resilience strategy.

vb
Janos
Chapter 7- Written by Janos Baombe

TIPS ON HOW TO PREPARE AND SURVIVE YOUR NIGHT

SHIFTS

Night and twilights shifts are integral part of our beloved and noble
specialty. We obviously could not imagine emergency care not being
delivered anywhere in the world on a 24/7 basis so love it or hate it, you
will have to embrace the fact that as an emergency physician or an ED
nurse, you will be undertaking some unsocial shifts.
It is probably fair to say that some of us hate working night shifts.
This strong statement is based on a personal observational study I recently
conducted on social media (Thanks Nicola for allowing me to use this).
For others however, working night shifts might be more convenient
because of child care issues or because of a second job.
You should make no mistake though, unsocial hours do take their toll
on both your physical and mental health. If you do not follow some basic
rules on sleep hygiene and coping techniques, you are likely to suffer from
burnout, depression and potentially other health problems.
In recent years, there has been some analogy drawn (rightly?
wrongly?) between our profession and the aviation industry but this is could
be a separate blog post on its own right (see further reading section below).
In this post, I am attempting to cover some tips you can use to prepare
for your night shifts and how to recuperate from them.
We had in two previous separate posts covered the topics on sleep
hygiene and how you could look after your own mental health so please
refer to those posts ad nauseam and p.r.n.

The circadian rhythm: an intro

You will remember from your medical school studies that our bodies
are regulated by an internal body clock located in the hypothalamus. The
self-sustained oscillations created are spread out over a 24-hours period.
They regulate everything from your body temperature or your blood
pressure, your coordination/reaction time to even your testosterone
secretion or bowel movements!
Thinking about this cycle, it is easy to understand why it is so
unnatural to work a night shift and then sleep during the daytime. The
circadian oscillations can however be adjusted to the local environment by
external triggers, like light and temperature, and this is extensively used by
NASA for their astronauts and lately in civil aviation too: the new
Dreamliner jet by Boeing has internal cabin lights that adjust not only to
external lights but also the season outside the plane.
 Working a twilight or night shift therefore means fighting against
these natural rhythms. Although you can somewhat adjust your internal
pacemaker, it usually requires a few days of adaptation and effort. In the
UK, most of night shifts for emergency medicine physicians are now split
into two blocks Monday – Wednesday and Thursday – Sunday. I however
was “lucky” enough to work in the old system as a trainee where we used to
work a full block of a week of night shifts.
The below post is based on no or little evidence but mostly on my
own experience in the relatively short decade and a half I have spent
working in emergency medicine and its related fields.

BEFORE STARTING YOUR NIGHT SHIFTS

No big night out
Going out for a heavy night out with your friends or a Chardonnay-
rich dinner the night before you start your night shifts is not a such great
idea. Spend some time relaxing and allow time spent with your friends and
family as you might not have the opportunity to see them for a short while
as you start your nights.

Get some sleep before your start

Make sure you sleep plenty the night before your shift. Wake up
following your natural pattern as dictated by your body clock (no lazy lie
in!) and do something productive until the afternoon when you should try
and have an afternoon nap. This technique should allow you not to mess up
your internal rhythm before you even start your nights.
Replacing traditional night shifts with “casino shifts” may help. These
are often comprised of 2 short shifts from 10pm-4am and 4am-10am with
the notion that each provider would get sleep during the “anchor period” of
the circadian cycle, 2am-6am. Small studies have shown this feasible,
preferred by many, and perhaps perceived as better.
Again, have a look at our blog post on how to maximise your sleep
here.
Prepare your granary
As you will be mostly work at night and sleeping during daylight
hours, try to cut out on wasted time spent shopping in supermarkets after a
shift by loading up your fridge with (healthy!) food and drinks in advance.
Online shopping, you say? Forget it for when you are on nights: there’s
nothing more annoying than the buzzer going off to let you know your
weekly shopping has arrived when you have just managed to fall asleep.

SURVIVING THE NIGHTS

Be aware of your downtime
Your deepest sleep is programmed in your above-mentioned
biological pacemaker at around 2AM so try and take that mid-shift break at
around this specific time period if possible. This should hopefully minimise
the risk for clinical errors too. Your lowest body temperature is at around
4AM so a hot drink or that fleece would be welcome at this time.

What to eat/drink and what to avoid

Remember that “lunch”for you will be in the middle of the night so
pack something you’ll enjoy ahead of your shift. Treat yourself but avoid
spicy and heavy foods as they are more likely to contribute to fatigue. As
always some sugar is good, too much is bad so go for a balanced diet. Make
sure you stay well hydrated as you are likely in our profession to be on your
feet all night.
Do not forget to use the toilets (easily done on a busy shift!).
I was surprised to read some weeks back that you can feel the effect
of coffee within half hour of ingestion (some placebo effect too maybe?)
and the effects can last up to twelve hours! So remember this and go easy
on coffee and caffeine loaded energy drinks.
 Also remember that tea is not necessarily a better option: it does
contain more caffeine than coffee so it will all depend on how diluted you
have it. Herbal tea is caffeine-free and an alternative option.

Be zen
Try to avoid conflicts if you can. Remember that we are all tired in the
middle of the night so conflicts probably happen more often during a night
shift. This is true between healthcare professionals but also between us and
frustrated patients/relatives. Take a deep breath, smile before you try to
defuse a difficult situation. Use de-escalation techniques. Consider
attending a conflict resolution training day if you have not come across this
yet. Seek the help of a senior early before you lose your temper.

AFTER YOUR NIGHT SHIFT

Getting home from work
I cannot emphasise this strongly enough: if you have a long drive
ahead of you after a night shift, please think twice before getting behind the
wheel to drive home! Exhausted drivers are a threat to themselves and other
members of the public too. It is simply not worth the risk(s) and is a
catastrophe waiting to happen. We tend to overestimate our driving skills
and driving home after a night shift is not ideal as our reflex times are
significantly impaired. Consider therefore leaving your car home and use
public transport instead. If you have a lengthy commute to do, book a
hospital accommodation or a hotel nearby even if it is only to sleep a few
hours before heading home. Your family and friends will be grateful to have
you back home unharmed after a night shift even if it means you get there a
little later.

Getting into bed

If you have to work more nights, get to bed straight after a little snack
and shower. Do not get sucked into distractions like TV: this is not the time
to watch two episodes from the last season of Game of Thrones. Switch off
your mobile phone, close your blinds and bedroom door to minimise noises.
I am not a fan of ear plugs personally but consider them if like me you live
in the buzz of a metropolitan city centre.
Use your own bed and sleep alone (no further comment here)! Avoid
the couch in the living room.
Avoid smoking, caffeine or alcohol consumption as they are likely to
impede on those important hours of sleep that you desperately need.
Sleeping tablets? They are simply a bad idea!\

Recovering after a night shift

I know of some junior doctor or nursing colleagues who after a set of
night shifts try and stay up until sunset. I personally think it is a bad idea as
at this stage you need to recuperate on those lost precious hours. You
however probably do not need to sleep all through the day so it is OK to get
out of bed after a couple of hours of sleep. This should also allow you to go
to bed before midnight and reset your circadian rhythm back into its normal
pattern sooner. Try and do something you enjoy doing in the afternoon if
you are up and about: a little 5k stroll or a walk in the park will allow you to
replenish on that sunlight you have missed in the past days.

And as a closure…
One shoe does not fit all and it is evident that not all of the above will
apply to everyone as we are all different . The trick is to find the right and
balanced combination that works for you to try and minimise the harms
caused by the interruption of the circadian rhythm.
I hope you can take one or tips away from this latest post and
make your night shifts somewhat more bearable.

Be safe!
vb
Janos Baombe
THE TEACHING COOP COURSE
IN MANCHESTER

This year we are running the world famous Teaching

CoOp course in Manchester. Come join the St
Emlyn’s team for an incredible week of education in
the home of Virchester.
Chapter 8- Written by Natalie May

GET THE BEST FROM YOUR REST – SLEEP HYGIENE AT ST

EMLYN’S

Sleep is absolutely one of my favourite things in the world. It can also be

one of the most elusive. Almost all ED docs, by necessity, work some sort of
shift pattern. Given that pretty much every single website on improving your
sleep starts with “go to bed at the same time every night”, it’s not hard to see that
we could have some problems here.
Thankfully, there are things you can do to sleep better – and that will make
you feel better, be healthier and perform better in your job.
Sleep Matters
Sleep is really important for health – important enough that a recently
published study suggesting a correlation between having less than 7 hours sleep
and contracting the common cold made national news this week.
Most people need around 7-8 hours sleep a night. Some will require less.
But how much you need is less important than knowing that by getting less sleep
than you need, you accrue a sleep debt and you underperform. One of the most
often quoted studies suggested that performance on some tasks after 17-19hours
without sleep was equivalent to or worse than a blood alcohol concentration of
0.05%. Which is really important when you’re about to get behind the wheel of a
two tonne hunk of metal and drive home in it…
Understanding the impact your sleep patterns have not only on your health
but also on your ability to practice places greater emphasis on taking
responsibility for your sleep patterns and sleep behaviour. This means
recognising and adapting behaviours which are impairing your effectiveness
(like big nights out before work the next day). Take good care of yourself and
you’ll be better at taking care of patients.

The Royal College of Physicians has produced an excellent short guide to

working night shifts and much of the advice below is derived from it. Have a
read here

Sleep Basics
 Even if the rest of this post makes you want to sob in frustration (because
you have kids whose routine means that you can’t just go straight to bed after a
night shift), there are probably things you can do to improve your sleep hygiene
and get a better rest.
The quickest, easiest fix is to improve the environment you sleep in. To get
the best out of your rest, make your bedroom a room for sleeping in. Try to avoid
undertaking other activities (like working) in the room if you can but definitely
avoid doing them in bed (the first rule of sleep hygiene? “Beds are for sleeping
and for sex“).
The room itself should be quiet, dark and not too hot. Blackout curtains are
an excellent investment (although a sleep mask, if you can get used to wearing
one, is cheaper). Earplugs are also helpful for daytime sleep and are worth
getting used to.
If you are oncall and may need to answer your phone, consider having calls
put through to a landline phone so you can turn your mobile phone off, or
activating the “do not disturb” setting on your mobile (on an iPhone you can set
this so it will only alert you for phonecalls).
Use of electronics is a no-no – there is evidence that light exposure is key
to wakefulness through the suppression of melatonin production (more on this
later) and this study suggests that it is blue wavelength light which has the most
profound effect. The same findings have been replicated for e-Readers and for
self-luminous tablets before bed.
Beyond the light itself, if your phone rings or buzzes or lights up
overnight, it’s reasonable to see how that might disturb your sleep pattern – and
this study suggested that computer or mobile phone use immediately before
sleep was associated with problems drifting off. Part of this has to be the process
of winding down, so taking time to declutter your active brain before asking it to
shut itself off makes sense.
If you are someone who struggles to drift off, try sleep focused
mindfulness exercises. The purpose of these mindfulness exercises is to focus the
mind and, in addition to improving overall health and resilience, this often
results in sleep. These may be particularly useful when returning home after a
busy shift and are better for your sleep than alcohol, however tempting it might
be.
Lastly, if you are struggling to sleep don’t stay in bed tossing and turning –
get up and do something else. That doesn’t mean pick up your phone or start
working, but consider relaxation exercises, a bath or some relaxing music and
return to bed when you start to feel tired. Building an association between your
bed and sleep is important and often neglected. If you have no idea where to
start, apparently this is the most relaxing tune ever…!
Working Late or Night Shifts – Preparation
 It can be tempting to go out on a big night out the evening before you lose
a bit of your life to a series of late or night shifts, but this is counter-productive
for a couple of reasons; sleep debt and the effect of alcohol.
During your night shift you will accrue a sleep debt and being underslept
before you start will not help – especially if you have had poor quality sleep
which is the gift that alcohol brings; at all doses alcohol seems to cause “a
reduction in sleep onset latency, a more consolidated first half sleep and an
increase in sleep disruption in the second half of sleep.” In practical terms this
means being drunk the night before your first night shift will offset any benefit
you get from sleeping in because your sleep will be of poorer quality.
The Royal College of Physicians recommends a late afternoon nap, ideally
at least 2 hours’ duration, before your pre-shift routine begins. Once you get up,
try to get some light exposure. Ideally get out in daylight but artificial light does
seem to work as well – this will delay melatonin production. Exercise in the
evening shifts melatonin production til later on, increasing wakefulness so if
exercise is part of your normal routine (if it isn’t, try it!) it may help you to stay
awake during the shift if you exercise in the evening before work.

On the Night Shift

Light is helpful in maintaining your alertness. In the ED this is not usually
a problem (often to the annoyance of our patients) but in ward areas lights are
usually switched off to preserve patients’ sleep/wake routines as much as
possible (they have these issues too!). Thankfully studies suggest that
intermittent exposure to bright light is almost as effective as continuous – so get
out in the corridor every so often to keep yourself alert.
If you get a chance to sleep on your break, that’s great. Most EDs are
bleep-free so we don’t have to worry about that sort of interruption – however,
finding somewhere to get your head down for 20mins is a bigger challenge. If
you are going to sleep during your break it is advisable to let senior ED staff
(registrar/nurse in charge/consultant if present) know so that they know where to
find you if there is an emergency. Power naps (<45mins) are best – deep sleep
should be avoided if you might be expected to perform clinically with very little
notice.
Eat and drink as normally as you can – ideally as if it was a day shift – and
try not to be dependent on caffeine. Its effects are temporary and can make you
feel more tired after they wear off. The RCP suggests that immediately after a
nap is the most likely time caffeine will be useful.
Make sure you have eaten, had a drink, had a break. It’s easy to look at a
waiting room full of patients and feel guilty about having time for yourself but
don’t – your clinical performance will be better (and safer) if you are well-fed;
human factors affect your ability to practice medicine.

Finishing Nights

First and foremost, at the end of your shift – don’t drive tired. Please! The
consequences can be devastating. The risk is highest at the end of a run of night
shifts, where the sleep debt is at its greatest and you are unable to accurately self-
assess the degree of your impairment.

When you get home, whether or not you are due back at work again that
evening, aim to go straight to sleep, avoiding distractions as much as possible. If
you are hungry, consider that eating a large meal before bed will also disrupt
your sleep pattern – I used to have breakfast at work before going home.
Avoid smoking, alcohol and sleeping tablets before going to bed. It is
normal to wake during the daytime (just as it’s normal to wake overnight) – if it
happens, just relax (PUT THE PHONE DOWN!) and you will usually drift off to
sleep again. If you can’t get back to sleep, get up after 30mins but keep the lights
low and aim for a late afternoon nap of a few hours before work.
If you have finished nights (hurrah!), get up, get some light exposure and
do daytime things. The RCP says that post-nights partying is out too – for most
effective return to daytime wakefulness, go to bed that evening at a sensible hour
and get up normally the following day.

Sweet Dreams Are Made Of This…

 OK, so the likelihood of you doing all these things differently after reading
this post is small but there are some important quick wins in here. Be honest
about your sleep hygiene, take responsibility for your sleep’s wider effects on
your life and consider what you can change.
The talk by Haney Mallemat at SMACC US covered some of this (in
addition to tips for rota masters on writing work plans which favour productivity
of your staff using staggered shift patterns) – check it out here.
Until then, sleep well, sweet dreams – and I hope you get the best from
your rest.
vb
Natalie May
Chapter 9- Written by Janos Baombe

HOW IS YOUR EATING HYGIENE AT WORK?

We often forget that despite being superheroes on a daily basis (we

save lives after all – let us celebrate it) we are also all human. It is not easy
to incorporate a regular and healthy diet in the 24/7 shift pattern that defines
EDs and many other specialities around the globe. We love our profession
and try to cut down on our meal breaks to get back out there and do what
we enjoy doing. We do, however, need to improve on this as you cannot
look after others if you do not look after yourself.
 This post is best read in conjunction with our other wellbeing posts:
how to prepare for your night shift (1), how to look after your own mental
health (2), sleep hygiene in the ED (3), be well and be a better critical care
clinician (4) etc…
Here comes the usual disclaimer: the following is based mostly on
personal experience having worked as a medical doctor for well over
a decade now. I am sharing this hoping that my colleagues will not make
the same mistakes I did years ago. You might want to adjust these
suggestions to your own lifestyle or ignore it in full!

Bring your own food

This is recurrent and basic advice but let us be honest: most of the
hospital restaurant do not provide healthy, varied food options. These places
are designed to feed a large cohort of staff, relatives and visitors so their
emphasis is on producing large quantities at rapid speed and this often
comes at the cost of quality. Who has not come across “chips and cheese”
or “dry empty salad” as the only options in their canteen? The last thing you
fancy is a light salad when you are working a long shift constantly on your
feet, tirelessly using your neurons burning carbohydrates at an
unimaginable rate. You often opt for the easy option of buying the
unhealthy meal (of which I indulge myself very often with a colleague –
you will recognise yourself) or you go for the salad but do not feel satisfied.
This is then more likely to be followed by unhealthy snacks to stop that
remaining stubborn hunger or exhaustion.
Cooking a larger portion at home the night before and taking the rest
for lunch the next day is an easy way around this problem. You can not only
design a balanced meal (low carbs and fat, more protein, varied in
consistency) but you can also bring your favourite food to work. It is a win-
win situation. This should result in less frustrations and you are more likely
to regulate your satiety. It slid means if you only have a short opportunity
treat, you will not waste any time visiting and waiting at the canteen.

Eat less
 We are genetically programmed to eat as much as we can in order to
tackle periods of low food. This might have been true some thousands of
years ago when we were cavemen. Look at those horror stories on National
Geographic of snakes swallowing whole mammals and then going without
food for weeks, or of squirrels collecting food for the winter to come.
This probably does not apply to us anymore in the 21st century. I
know sometimes a shift feels like an eternity (!) but we rarely work a shift
that is longer than half a day (well, I hope so!). We therefore do not need to
fill our stomach up with (junk) food. You are also more productive with a
half full stomach only as precious blood circulation does not get stolen from
your brain to supply digestion. Have a glass of water before you start your
meal in order to decrease the amount you will eat.
You can also tackle this problem if you combine the next three pieces
of advice.

Have healthy snacks between meals

Ever seen those unhealthy cookies and sweets left on the nurses ‘ desk
by your colleagues? Of course, you have and we are all guilty of it! I do this
often to build staff morale (there is a positive correlation reportedly via
endorphins pathway) and help my colleagues who did not get on their break
on time. There must have been again something evolutionary behind it
engrained deeply in the primitive part of our brain. I never bring back
healthy fruits or carrot sticks. We all find them rather unsatisfying and we
tend to reach for the biscuits. Most of the cheapest, unhealthy options are
invariably strategically placed at tills at retailers so you are more likely to
get them than actual “proper” food. They play with human psychology and
we can actively fight this.
So next time, bag an apple, nuts or even a protein bar in your lunch
box. I try to keep one of these on my desk often. When that sugar dip
happens, reach for a healthy snack between meals or before your evening
commute home rather than those doughnuts!
Sit down at a real table
This is very important. Why would have your lunch standing or
during a walk to the other side of the hospital? “I will grab a sandwich as I
walk there” is not good habit at all. Animals demarcate their territory and
most dog-related incidents I see are when a toddler has stepped on the dog’s
bone. Animals are very precious about their eating territory (their “table”).
It is so much nicer to enjoy your lunch/dinner when you sit at a proper
table with a comfortable chair. Also, you have just been up on your feet for
the few past hours so why would you not just sat down for those 30 minutes
of self-enjoyment? This can also be the perfect opportunity to have a social
chat with colleagues or simply have some time out.

Do not multi-task during eating

I am guilty of this all the time. I sit down, start eating and then
undertake to check my work/personal emails (and yes, Twitter or
Facebook!) whilst I am chewing my food. My colleagues and I know that I
am not great at multi-tasking despite being an emergency physician (I keep
being reminded by my female nursing colleagues!).
I also love watching the news in our staff room whilst I am eating.
Not a good idea either, especially as most of the news lately seems to be
related to catastrophe and political battles. Do we not see enough of those at
work?
So, switch off your bleep (if you can), turn away from your desktop
screen, put your smart phone in your pocket, and contemplate the nutritious
food you have prepared for yourself earlier in the day. Close your eyes a
few seconds to enjoy the moment: you are on your break. This is “me time”
after you have spent hours sorting out other people’s problems. Digestion
reportedly works better if you eat slowly, as you chew more effectively and
this puts less stress on your digestive system. Eating plenty with intention
or mindfully also means you usually feel more full for longer.

Drink plenty
 Avoid fizzy and sugary drinks that are again so easily available in
most hospitals either from retailers or strategically positioned in waiting
rooms/hospitals corridors. They have a high glycaemic index but you’re
best getting your “carb fix” from healthier sources (like the above-
mentioned fruits). Bubbles will fill up your stomach, and whilst you’re
likely to eat less as a result, you are also more likely to feel bloated and this
will increase the energy you need to digest your meal. So the best option
is… plain water!
We are very bad at hydrating ourselves anyway during a shift as we
are constantly busy, so at least try and compensate for this by assuring
adequate water intake during your break. Also, we are guilty of sipping
coffee or tea to keep us going but both have diuretic effects and therefore
more likely to dehydrate us even more. Cut down on fizzy drinks and
tea/coffee and drink the basic element on which life has thrived on this
planet: water! Drinking too much caffeine during a shift can stop you from
having much needed sleep in between shifts.

Relax during and after eating

Try and combine the above tips to enjoy not only your break but your
meal. Eating is a basic and essential physiological need.
Finished your food and still have some time before getting back on
the shopfloor? Now, you can turn on the radio or listen to some light,
relaxing and chilling music. It helps digestion but you are also more likely
to return to your clinical activities refreshed and with a smile.
Keep well people!

vb
Janos Baombe
Chapter 10- Written by Natalie May

IT’S GOOD TO TALK – DEBRIEF IN THE EMERGENCY

DEPARTMENT

There is so much I could write about the role and value of our own
humanity in the Emergency Department although much of it has been said
before by people far wiser than me. But there are situations when we are
caught offguard; when things don’t go as we had hoped, or when they do -
but a powerful and unexpected emotional reaction is evoked. For many of
us, as Emergency Department stalwarts, we habitually brush off emotion to
focus on our literally clinical day-to-day lives. But failing to acknowledge
the value and importance of our intuition and reactions in challenging
situations exposes us to cognitive bias and we should learn to use our
emotion to moderate our logical side.
I’ve talked previously about the potential value of debrief after
stressful situations, a concept being used and analysed more with the
acceptance of the impact of human factors and the evolution of high-fidelity
simulation training (although it remains controversial to some extent). But
is there a best way to run a debrief in this situation?

When to Debrief
Situations
There are three situations where debrief has potential value; after
simulation, as a regular scheduled event, or after a critical incident. I should
explain at this point that much of the literature refers to “critical incident”
debrief in a broader sense than the NHS definition, encompassing situations
where thing have gone wrong but also those difficult and unexpected times
such as cardiac arrests, critically ill patients or difficult relatives. I’m
mainly talking about these “critical incidents” below.
Timeframe
Informal debrief generally happens almost immediately after any
uncomfortable clinical experience as we decompress to our colleagues in
the coffee room. For formal debrief it is helpful to allow some time to pass;
most debriefs are undertaken within a week of the event itself. The cost of
this delay, particularly in the inevitably shift-based ED, is attendance levels
among the staff.[/DDET]

Why Debrief?
Making Sense
 It is important to allow people to talk about and make sense of
emotional and psychological responses to stressful situations. Reflecting on
their impact on decision-making and on other team members can build
stronger team relationships and enable modification of unhelpful
behaviours. It is also essential to recognise that the effects of these
situations extend beyond the Emergency Department itself.
Identifying areas for practice improvement
Even in successful resuscitations areas for improvement can usually
be identified. Simple stock issues, for example, may go unnoticed by senior
members of the medical team but cause the most frustration among nursing
staff. Allowing time for all members of the team to highlight areas for
improvement can generate meaningful and shared objectives for change.
Identifying areas of good practice
Again, even in resuscitations where everything seemed to go wrong,
there is usually good practice. Consider the oft-talked-about, tragic case of
Elaine Bromiley – of course, there is much to learn from this situation and
the human factors involved – but has anyone stopped to praise the nurse for
bringing the surgical airway trolley? Positive reinforcement is as important
as recognising areas for improvement.
The rest of the story
We often joke that the Emergency Department suits our short
attention span but I have argued before that not knowing what ultimately
happens to the patients we care for divorces us from an ability to care.
Debriefing a few days after the event can fill the gaps and provide a
perspective of ED care we are not always privy to.

Barriers to Debrief
Before starting a debrief, it’s important to be aware of the potential
barriers to meaningful discussion.
• Criticism of own department: There is a natural reticence
towards being too critical of our daily working environment, but the debrief
must be a safe place for concerns to be raised. In the era of Francis the
ability to speak freely on matters of clinical concern is paramount. Consider
carefully whether staff not directly involved in the event itself should
attend.
• Emotion vs facts: Beware allowing emotion to overshadow
or colour “facts” of the event; agreeing a shared account of the facts in the
first instance can help to maintain control
Power balance: Consider the seniority and status of the debrief
facilitator. Junior staff of any discipline must be able to speak freely without
wondering “can I say this in front of him/her?” Every effort should be taken
– including explicit explanation – to ensure that even the “formal” debrief is
comfortable and relaxed
Availability: Staff should be released from clinical duties to attend the
debrief. An immediate debrief will usually capture all staff involved; a later
debrief will usually mean that at least one or two staff cannot attend. While
this may be unavoidable it is important to offer non-attendees the chance to
talk about their own perceptions and to contribute to the debrief, potentially
by secure email or written statement as appropriate.

Top Tips
Below I’ve paraphrased 12 tips on debrief published in the Joint
Commission Journal on Quality and Patient Safety.
1 Decide on the purpose of the debrief – regular event versus
critical incident
2 Create a supportive learning environment and set ground
rules
3 Encourage attention to teamworking processes (think of the
human factors you might identify were this simulation rather than real life)
4 Train team leaders in debrief (an EMJ article found only
13% of those attending a debrief after failed paediatric resuscitation had
received any training on debriefing)
 5 Ensure an appropriate, comfortable and private environment
6 Focus on a few critical performance issues – don’t
overwhelm
7 Describe teamwork interactions and processes
8 Support feedback with objective performance indicators
9 Give more feedback on processes than on outcomes
10 Balance individual with team oriented feedback
11 Shorten delay between task and feedback as much as
possible
12 Record conclusions and goals/objectives for change

How to Debrief
My favourite model for debrief is below; it comes from the
International Critical Incident Stress Foundation and can be found here.
It describes a step-by-step framework for semi-structured discussion
which I have adapted a little for the Emergency Department.

Introduction and ground rules

Individual introductions and explanation of roles, plus explicit
explanation of the purpose of debrief and the safe environment – think
Chatham House rule
Facts (describe what happened)
This is probably best done in a chronological manner; a timeline can
be recorded if helpful. Facilitate the group to describe and agree an account
of factual events
Thoughts (personalise the processes)
 Facilitate discussion about thinking processes; if something went
wrong, ask what participants were thinking at that moment and why. This
can include verbalised emotional responses (“I just felt so helpless”) or
clinical decisions (“I remember thinking that the blood pressure was the
most important thing”)
Reaction (what bothered you most and why)
This offers participants the opportunity to express and deal with
pervading thoughts about the event. There is often a single issue, image or
event each person dwells on, and understanding why this has provoked a
response is thought to be key to breaking the cycle of flashbacks to the
event
Symptoms (evolution of feelings and reactions/flashbacks since
event)
In “victims”, this step is used to discuss the evolution of feelings in
the time that has passed since the event with focus on PTSD symptoms. In
healthcare professionals, it might help to discuss coping strategies; “what
did you do after the shift? Did that help? How did you feel the next
morning? Do you feel the same today?”
Teaching & Learning from Events
The step of identifying areas for change is paramount; good practice
can also be highlighted here. Making practical changes from a tangle of
thoughts and emotions helps the participants not only to move on from the
past event but to effect behaviour change for future events.
Re-entry (questions, summarise & follow-up plans)
Closure is important; an opportunity to ask questions is especially
useful for junior staff who may still not know why or how a particular
action or decision was taken. A summary of action points should be agreed
by the group and ideally allocated for action.
And, of course, staff who need more support need to know where to
turn. If this is you, there are always people willing to listen; your
colleagues, partner, educational supervisor, clinical director, foundation
tutor, friendly registrar, occupational health doctor, GP, the BMA to name
but a few. Don’t keep it to yourself.

A similar structure might be employed on a one-to-one basis in the

situation of debriefing a junior after a clinical error. These situations can be
just as traumatic as a failed cardiac arrest and warrant careful handling to
ensure that meaningful learning takes place without causing lasting damage
to the trainee.

Some Alternative Models

Below are some other models which might be of use
DEBRIEF model – by Hayley Allan – debrief in the context of reflection
and educational theory.
DISCERN model for immediate feedback

vb
Natalie May
Chapter 11- Written by Natalie May

WHO’S THAT GIRL? IMPOSTOR SYNDROME AT #SMACCGOLD

Ed -this blog was written at the time of the SMACC Gold conference in
2014. It talks about Natalie’s experience at that time. However, we still feel
the same today and so it’s just as relevant in 2018.

Natalie - I want to let you into a secret. I’m an impostor.

OK, that’s not quite true. I’m a 34-year-old (shock!) Emergency Medicine
trainee with a penchant for karaoke and a passion for education, but I’m really
not anybody special. I play the piano (badly) and can struggle through a basic
conversation in French or German (even more badly), I have never achieved
honours at university or prizes in my post-grad exams and my list of published
articles in respected journals is… well, lacking.
So when I found myself sitting onstage, sweaty-palmed and tachycardic,
waiting to talk to a packed roomful of people about paediatric EM at SMACC
Gold one thought was overriding – “what am I doing here?!”
It wasn’t the first time that fortnight either. I headed to SMACC off the
back of an incredible opportunity not only to teach EM trainees in Fiji but also to
watch and learn from teaching sessions by my talented and passionate colleagues
Nick & Iain – an opportunity which is infrequently afforded in the midst of ED
service pressures. There is a lot you can learn from others’ teaching styles and
their honest critique of yours. So there I was, having an amazing experience in
Fiji and then in Broadbeach. Why on earth did I deserve that?
 A potential answer is, I didn’t… But it’s the human tendency to
obsessively analyse this perception that can be crippling. I promise you that what
follows is not intended to be a self-pity party but my reflection on what makes
SMACC so different from other conferences.
The impostor syndrome is well documented and is a little different from
the occasional feeling that we are incredibly lucky to find ourselves where we
are. This paper, published in 1978, described women who – despite having high
achievement or academic excellence – maintain a belief that they are not
intelligent and in fact that they have “fooled anyone who thinks otherwise”. The
impostor syndrome does occur in men albeit to a lesser frequency and intensity;
the great Joe Lex says, in his inspirational talk An Old Dog Learning New
Tricks:
There’s been a dreadful mistake. They’re going to find out that I’m not
really competent, I’m not really qualified to do this job. I will confess – I still feel
this way about once a week.
Joe’s 45 Years on the Frontline talk now also includes the following quote I
shared with him at SMACC2013 after I was struck by how his admission
resonated with me:

We can feel like impostors regularly in our clinical practice, but as Joe says it
tends to be in a low-level, infrequent way. To constantly feel like an impostor
would be paralysing and we would struggle to treat our patients effectively.
 But am I really an impostor? Having been invited to speak at an
International Conference somewhere along the line someone must think I’m
good at something. And to be fair if you’ve met me in person you probably
realise I don’t come across as lacking confidence – and I don’t have a problem
with public speaking; I have an A-Level in Theatre Studies, am very much at
home with a karaoke microphone and spoke at the CEM conference in 2013 on
the role of social media in medical education with only about an hour’s worth of
butterflies-in-the-stomach beforehand. But SMACC was different, and I know I
was not alone in feeling an unprecedented weight of expectation. I know that at
least four other speakers experienced similar feelings of performance anxiety
although I won’t name them without their permission. The Game Face is an
important mask we all need to wear at times.

At SMACC, the pressure to deliver an incredible talk was intense and I had
felt it continuously for at least two weeks. It was also unspoken, and intrinsic in
origin. There was no-one following me around, whispering in my ear that my
talk had better be pretty bloody good, but I was unable to escape from that
mindset. I’ve spent a lot of time since the conference trying to work out what
made this talk – 20 minutes, in a concurrent session (so not even on the main
stage) – such a huge deal for me.
I know that I hold in high esteem the quality of education delivered at
SMACC (and I have an investment in preserving its quality). But more
importantly, it’s about the people who attend SMACC; these are people who
really, genuinely care about delivering the best in Emergency Medicine, Critical
Care, Prehospital Care and Rural General Practice – many devote hours every
week to generating FOAM blogs, podcasts and teaching resources – and because
of this they are people whose opinions I really care about. They simply feel like
family and I have a crazy urge to make them proud of me.

Where SMACC2013 was a little male-dominated and (in my opinion, not

unfairly) criticised in places for feeling cliquey, SMACCGold was undoubtedly
full of love. The unsolicited (and perfectly made to my exacting specification)
cup of tea handed to me by Cliff Reid as I left the stage after my talk told me I
shouldn’t have worried so much – I could be appreciated for my passion and
contribution as much as the clinical and academic content of my talk. And even
at the second meeting of the Fabulous Females of FOAM (not just for women –
open to anyone feeling like an impostor, regardless of gender) the air was
different – the meeting was never about man-hating but this time there was a
palpable atmosphere of mutual encouragement, openness and appreciation.
I firmly believe that Impostor Syndrome is the reason the FFF needs to
exist, and why women remain under-represented in the FOAM world. SMACC
is filled with the great and the good; is the case really that none of us feels great
or good enough to be counted among them but we’re too scared/proud/worried
that we might be right to admit it openly?
If you saw me at SMACC you might have noticed I spent a lot of time in
Amy Cuddy’s famous Power Pose – do watch her incredible TEDtalk on
overcoming Impostor Syndrome if you have time. I practiced a great deal of self-
talk and it did help. On the final concurrent of the final day of SMACC I stood
up and talked for twenty minutes about Paediatric Emergencies. I can barely
remember a single thing I said.
At heart, SMACC is just another conference – but it’s not just another
conference. SMACC made me feel like an impostor, but it also made that
completely ok. It wasn’t a hostile hotbed of arguments and determination to
show speakers up but a meeting of friends and family and an incarnation of our
daily struggles against disease, deprivation and death. And when we fight the
good fight together we come to value the part we each play and learn that we are
much stronger together than we can ever be on our own – and we find ourselves
resolving to be the very best that we can be, impostors or not. So bring on
SMACC US – I’ll be there, perfecting my power pose.
 In heartfelt gratitude, to everyone who attended and tweeted about
SMACC Gold; you made it what it was – thank you.
vb
Natalie May
Chapter 12- Written by Laura Howard

THE ED SPA

The ˜ED Spa is designed to be a safe space within an Emergency

Department, a place that is completely non-clinical and separate from
the coffee room. A place where any member of staff can go for a time
out, a cry, a rant or just a bit of space to 'be'. Our room in Virchester,
looks and smells completely different to the rest of the department, you
can walk in and know you are in a non-clinical area. Everything in the
room is based around the “5 ways to wellbeing”. We have been open
since 28th July 2017, it has been an absolute joy to see the Spa in
action.
It took Kirstin (aka Dr Ballantyne) and I over 6 months of planning to
get up and running. I wanted to share why creating the SPA became a
passion, and the theory behind it. Most of all my heart behind this blog is to
share how we all could have an “ED Spa” in our lives, and explain why I
believe we should use these tools while we are well, to help us in the tough
times.
The need for a physician to look after themselves to feeling good and
function well (wellbeing) is not a new. An engraving found on a monument
dated to 22 AD says this:
“These are the duties of a physician: first: to heal his mind and to
give assistance to himself before giving it to anyone (else)"1
So how did the ED SPA even become an idea?
I personally did not take the need to look after myself seriously until I
was very broken, events stacked up and I was left wrestling with the idea
that I did not want to be and was not ‘strong’ enough to be a doctor any
more. My identity was crushed. In this time, I was loved well by family,
friends and colleagues, I picked up tools to help me process the issues that
had arisen. I came out of this period as a very different person and clinician.
My eyes had been opened to the effects work can have on not just me, but
also my colleagues.
This lead me to design a qualitative research project exploring “How
Events in Emergency Medicine impact doctors’ psychological wellbeing”.
The full results of this project will hopefully be published soon. This project
involved conducting narrative style interviews from emergency physicians,
we reached data saturation at 15 interviews however performed a total of
17. The data was then analysed using framework analysis, from which
several themes emerged. Every clinician that I spoke to had a story to tell,
of a case or situations at work that had profoundly affected them. These
quotes sum up why I was passionately moved from research into action.
One interviewee said this
 “I have been a very well person, and I am actually very
confident. I am very outgoing and it absolutely broke me”
Another said this
“The net result of all that was, I certainly didn’t sleep
properly for 3 and a half years. I thought about it every day except for a few
days on holiday and it had a huge impact on my life”
What is the ED SPA and what is the evidence behind it?
First of all, there is no one size fits all approach for this, you need to
find your “thing”. The fabulous Liz Crowe explained this here:
http://stemlynspodcast.org/e/wellbeing/
The UK governments Foresight program together with the New
Economics Foundation created five Evidence based actions to improve
personal wellbeing (5 ways to wellbeing). This is the bases of the ED SPA,
everything done in this room and from this room, encompasses one of these
5 ideas.

1.Connect
Invest in relationship, as Liz Crowe explains in her SMACC talk, have
a work husband or wife. Strong meaningful relationships will encourage
and support you.
Feeling valued by other people is a fundamental human need, both at
work and in your personal life. Creating a community at work is something
we do well in EM; working in an Emergency Department is true team work.
That feeling of community gives a sense of familiarity and increased self-
worth. If you’re a team leader, make sure you spend time encouraging and
supporting your team. Mary Freer gave a really inspiring talk about
compassionate leadership at the recent Don't Forget the Bubbles conference
about compassionate leadership. As a leader you have the privilege of
setting the tone and culture in your department.
Connect with your family and friends. There is a link between the
total number of close relatives and friends (primary group size) and the risk
of developing common mental health problems. A primary group size of
three or less is a predictive factor for the development of common mental
health disorders in the future.2
Get together over coffee and cake or a few drinks after work (all in
moderation!) to create and maintain meaningful relationships. Set time
aside to invest in relationship with those around you. Get outside and
connect with nature. Parties and nights out, did not need any help to be
arranged by us, these are already plentiful! We have used coffee cups
planted around the department to try and promote connection. We also have
had the guide dogs in the SPA to allow the staff to connect with nature and
each other, this was very well received.

2. Be Active
Find the thing that you enjoy that gets you active
Participating in physical activity lowers rates of anxiety and
depression, as well as preventing cognitive decline.3,4 In terms of mental
wellbeing, the exact recipe (type, duration and frequency of physical
activity) needed for positive effects is not clear. It is known that engaging in
physical activity reduces negative thoughts whilst giving a sense of
empowerment and self-mastery.5 As little as ten minutes exercise, 3-5 times
per week, is known to improve mood and reduce symptoms of depression.
Here in Virchester there is a well established running club, for novices to
experts. We have taken our team out for activity days, climbing, rafting, and
team challenges all free to the participant and facilitated by a local scout
club. These were a fantastic success, taking time to invest in our staff, help
them get connected in a setting out side of work as well as getting active.
Try running similar days for your department.
Liz Crowe has established a walking club in her critical care,
whatever your passion is find it. Before sitting down in front of your
favourite box set , spend some time getting your heart rate first.
As well as getting active, think about what you eat and drink and
impact of nutrition on stamina, concentration and decision making during a
shift. Get off the sugar roller coaster of caffeine and biscuits. Shift working
can make it very difficult to do this well, we have looked at this here at St
Emlyn's.

3. Gratitude
There is a lot of research showing kindness and gratitude have many
positive affects on wellbeing. Neuroscience research has found that the
neural response to social co-operation is rewarding.6 Kindness and gratitude
increase your serotonin, and oxytoicin levels have been shown to increase
your energy levels and give you pleasure.
Creating a culture of thankfulness, performing random acts of
kindness, creating gratitude lists. These are simple and effective tools.
Download a random acts of kindness calendar, for yourself or your
department, try and follow it. Create a gratitude board in your staff room,
integrate gratitude lists into your handover structure.
We have a gratitude tree in the SPA, this is some of the things written
on there:
The SPA also has a wall, that demonstrates our gratitude towards the
staff and shows them how thankful we are for all they do:

4. Keep Learning
Every day in health care is a school day, in a medical career is that we
will never stop learning, from every day, from every patient. Evidence
shows that continual learning increases optimism, efficiency and
satisfaction 7.
Make a list of the things you had always dreamed of being able to do,
how could you learn some of those skills, are there classes you can take.
Can you carve out a protect time to pick up that hobby you love.
The SPA contains a bespoke library, the books here promote reading
for pleasure, healthy eating cook books, Â books that teach a wide range of
wellbeing tools, and books about decision making. All these books were
from recommended sources such as books on prescription.

5. Take Notice
Paying attention to the things around you in the moment, and how you
are feeling.
While the idea of mindfulness will fill some of you with dread, please
remember this is a tool kit, find the ones that work for you. Being present in
the moment, taking notice of how you feel and what is going on around
you. Training yourself to be aware of sensations thoughts and feelings has
been shown to increase your sense of wellbeing8.
Beyond this, allowing yourself to feel your feeling is vital, sadness,
anger, frustration are all perfectly valid emotions, and can often be felt
working in emergency departments. Its normal. Self-awareness, will allow
you to address and move through these feelings. Try reading ˜The Upside of
your Dark side by Todd Kashdanâ” for more on this.
For those who want to give it a try, the Head Space app is a fantastic
place to start, or if you like books, 'Into the Magic shop' is written by a
neurosurgeon about his experience of the practice of mindfulness.
Creating a culture within your department, where feeling and
emotions can be expressed is invaluable.

The bottom line

I believe passionately that investing in your self is the most valuable
thing you can do. It doesn't always mean being 'happy', it means looking
after your self and finding the things that make you the best version of you.
Doing this will help you flourish, and will improve your patient care. There
is no one size fits all answer to do this, I hope this blog has give you some
ideas for you and your department
BW
 Laura

References
1. Prioreschi P. Physicians, Education, Ethics, Hospitals, Public
Health . In: A History of Medicine: Roman Medicine. Vol 3.
Horatius Press; 1998:0-793.
2.BRUGHA TS, WEICH S, SINGLETON N, et al. Primary group
size, social support, gender and future mental health status in a prospective
study of people living in private households throughout Great Britain. P.
2005;35(5):705-714. doi: 10.1017/s0033291704003903
3.Studenski S. From Bedside to Bench: Does Mental and Physical
Activity Promote Cognitive Vitality in Late Life? S. 2006;2006(10):pe21-
pe21. doi: 10.1126/sageke.2006.10.pe21
4.Colcombe S, Kramer AF. Fitness Effects on the Cognitive Function
of Older Adults. P. 2003;14(2):125-130. doi: 10.1111/1467-9280.t01-1-
01430
5.Dishman RK, Berthoud H-R, Booth FW, et al. Neurobiology of
Exercise*. O. 2006;14(3):345-356. doi: 10.1038/oby.2006.46
6.Rilling JK, Glenn AL, Jairam MR, et al. Neural Correlates of Social
Cooperation and Non-Cooperation as a Function of Psychopathy. B.
2007;61(11):1260-1271. doi: 10.1016/j.biopsych.2006.07.021
7.Feinstein L, Vorhaus J, Sabates R. Learning through Life Challenge
Report. . The Government Office for Science, London ; 2008:0-93.
http://webarchive.nationalarchives.gov.uk/20121204182502/http://bis.gov.u
k/assets/foresight/docs/mental-capital/mental_capital_through_life.pdf.
Accessed November 27, 2017.
8.Carmody J, Baer RA. Relationships between mindfulness practice
and levels of mindfulness, medical and psychological symptoms and
wellbeing in a mindfulness-based stress reduction program. J.
2007;31(1):23-33. doi: 10.1007/s10865-007-9130-7
Chapter 13- Written by Steve Jones

BURNOUT IN THE ED: TOO TIRED TO SLEEP,

TOO WIRED TO WEEP?

It is stupid o’clock in the morning. I am wide awake and have been now
for two hours. I do not have the excuse of sleep disruption through night shifts
because whilst I do work increasingly late clinical shifts, the focus of my efforts
is keeping the ships sailing: I am a clinical director (CD). Ironically, I think that
tonight’s insomnia is because I am on holiday from today and I am thinking
through what I may not have finished or handed over thoroughly enough. I
suppose that this means I am stressed and it got me to thinking about the paper
by Yates et al recently published in the EMJ. This is the opening line…
So at least I am not alone (I know I am not before you start to worry about me).
The paper goes on to compare ED staff to orthopaedic department staff,
including nursing and admin colleagues, across a number of measures including
the General Health Questionnaire-12, Hospital Anxiety and Depression Scales
and the Brief COPE. Their headline message is that ED physicians, but not other
ED staff, reported increased psychological distress although clinically
significant levels of general psychological distress were above
general population levels in all staff groups. Whilst I think there are method
issues with the paper and the results need to be carefully interpreted (and would
be better fully reported) it does describe some reasons why I do not need to
worry so much and should probably just go to sleep. You can read the full paper
by clicking on the abstract below

My real succour came from the coping strategies that were described.
Admittedly they did some jiggery-pokery with the Brief COPE classifications in
order to describe three “meaningful” strategies:
 1 problem-focused (includes active coping and planning)
2 adaptive emotion-focused (includes acceptance, seeking
emotional support, positive reframing, humour, religion and self-distraction)
3 maladaptive (includes denial, behavioural disengagement,
venting, substance use and self-blame)
I am sure that we can all recognise times when we have used some or all of
these ourselves; I certainly can. Importantly, the authors conclude that increased
psychological health was associated with the use of problem-focused
coping strategies and higher levels of social support at work. This is great news
for me (if you believe the results) because I have both now. Over time, more
through accident than design, I have developed a problem focussed approach
based on the wise words of one Mike Lambert (who was the first Accident and
Emergency “Tsar” in the UK) who I heard say that the only way to predict the
future of the specialty was to create it. Since then I have done my small part but
could only do so because of the great team here at Virchester (my social support
at work). So why couldn’t I sleep?
The problem I think was that whilst I had developed these strategies over
time I wasn’t clear how it had happened. More importantly, if there was a route,
could I pass it onto my staff to enable them to make the journey quicker than I
did? Whilst on one level this was important to me as an individual I did after all
have responsibility as a CD too.
So what else to do at stupid o’clock but open a conversation with Dr
Google using the search terms “stress emergency medicine”? On the first page
was an article from a geographically disparate group of emergency physicians
from the US of A. (2) They assert that awareness of the issue is an important
thing and early education of physicians on legitimising “wellness” is vital.
Wellness for them was the opposite of some of the negative aspects of our work:
• substance abuse
• circadian disruption
• sleep deprivation
• malpractice and fear of litigation
• exposure to infectious disease and death
• poor nutrition and access to exercise
 Again I recognise all of these – mea culpa – but please don’t tell my mum.
Whilst I seem to have near given up alcohol I am still certainly drinking too
many caffeine containing drinks. Although we have made strident efforts to
change the work patterns of the junior physicians to reduce circadian disruption I
have not (yet) managed to do so for my senior team here at Virchester. I certainly
can’t guarantee my own sleep soundness as I fail to balance work and life and
haven’t yet cracked it for my staff either. We always have some difficult legal
issues to contend with and whilst we do (I hope) provide support for our staff
during these it remains a pressure. Death…well…is part of life but still comes as
a shock for people starting out and as for nutrition and exercise do Haribo
Tangtastics and jumping to conclusions count?
I think it is worth saying then that whilst I can (mostly) cope I am a way
off providing a clear path for my staff. Maybe I could…no probably not…but
maybe…I may sleep on that and get back to you. Night.
vb
Steve Jones

References
1. Philip J Yates, Elizabeth V Benson, Adrian Harris, et al. An
investigation of factors supporting the psychological health of staff in a
UK emergency department. Emerg Med J 2012; 29: 533-535.
2. Gillian R Schmitz, Mark Clark, Sheryl Heron, et al. Strategies for
coping with stress in emergency medicine; early education is vital. J Emerg
Trauma Shock 2012; 5: 64-69.
Chapter 14
RHEUM FOR IMPROVEMENT

Ed – what if EM was your passion, but you also had a chronic disease
that made it even more of a struggle? How would you cope, what would
you do, and how could others help? Many people consider EM to be a
career for the young and fit, but is that right? The world is full of
wonderful clinicians who don’t fit stereotypes and we are missing a
trick if we cannot facilitate their careers. In this blog, one of the most
fantastic junior doctors we’ve worked with tells us her story of
ambition, challenge, and ultimately career decisions that should make
all of us think about how we look after trainees.
Harriet is a fantastic clinician and we thank her for sharing her story
below.
________________________________
Harriet
Emergency Medicine is an active and energetic specialty, requires you
to be on your toes, both physically and mentally, and is full of young and
inspired people. Junior doctors are drawn in by the excitement, the
unpredictability and the wide variation of obstacles that we face within a
single shift. We look up to the more seasoned registrars and consultants, all
from different backgrounds, who are mostly still enjoying what they do and
are keen to pass on their knowledge and enthusiasm.
Amongst these aspects of our training there can be, at times, less
enjoyable experiences. Long and alternating shifts, witnessing death and
dying, difficult conversations with patients and relatives, and the physical
strain on our bodies are also what we are signing up for. We are warned a
lot about burnout and advised to go on holiday whenever we get annual
leave, but really is this possible for most of us? Those of us with children,
elderly parents, no savings, or medical problems cannot always do that
freely. Annual Leave cannot be the only time we self-care. We all start new
jobs with determination, confidence and enthusiasm, but life gets in the way
and can often lead to us feeling demoralised and far from refreshed. Add in
a chronic illness and it can make the aspirations of successful training seem,
or actually be, pretty unachievable.
I have Rheumatoid Arthritis. I have always been rheumatoid factor
negative with preserved bone formation, and have severe pain and swelling
affecting most of my joints, most of the time. I was given a JIA diagnosis at
the age of 4, which stuck with me until I moved to medical school and
symptoms progressed and so it was reclassified. Now I am 28 years old,
have exhausted all the licensed (and unlicensed but individually funded)
biologic therapies. Methotrexate has been on my prescription list since
childhood and I have been taking prednisolone since 2003, resulting in
secondary adrenal failure and osteopenia, which led to a bone graft and
metal work in my wrist, and this year a new development of Cushing’s
syndrome.
Aside from the trauma and the acute issues we see as emergency
physicians we frequently look after patients who have many chronic
illnesses. Often I see patients who come into the department with
exacerbations of these issues, or increased pain and reduced mobility of
their chronic pancreatitis, arthritis or fibromyalgia. Part of me enjoys seeing
these people because I understand what they are going through, I have been
there and I also know I cannot fix them. So I talk to them (alongside giving
some analgesia), I do not tell them why I understand, but I empathise and
try to help them feel better. This is very rewarding for me and does
occasionally seem to have a positive effect.
I decided that I wanted to be a doctor when I was 8 years old and had
always enjoyed the time I spent in hospital. I never waivered from this
decision and I worked hard to achieve my GCSEs and A Levels with one
goal in sight: medical school. Five years there, two foundation years in
South London, and I decided EM was the path that would be right for me.
With the thoughts of excitement and unpredictability, trauma, variety of
presenting complaints, excellent opportunity for team work and working
with all specialties, I made the move to Virchester to be a Clinical Fellow
and started to build my CV for the career ahead of me.
For the past 20 years family and friends have witnessed my
determination and some success, and it is how I have presented myself to
others and on paper. Fortunately or unfortunately, I can be good at hiding
things and I am incredibly stubborn. The reality of my life and what is
happening internally is vastly different.
 I managed 18 months of full time work in the Emergency Department,
albeit with a few days here and there for sickness, before one morning in
April this year I woke up and I couldn’t get out of bed. That was the start of
a month being house and wheelchair-bound.
For 2 weeks I couldn’t walk at all; the next month I was able to get
out when taken in a rented wheelchair. By this point I was very low in mood
due to boredom, frustration, pain, and constant worry about letting people
down at work. This was the point when I realised why so many chronic
illness patients suffer with depression, or are alcohol or drug dependent. So
I decided to take matters in to my own hands and looked into what I could
do myself to change my situation.
After addressing the more immediate issues, I looked at my career
path. It took for me to be this unwell to realise that the Emergency
department is not the most suitable place for me to work. After nearly 12
weeks off (half at home and half non-clinical work in the department, for
the sake of my sanity!) slowly I phased back to clinical work and it was
really tough. I had forgotten how draining, how physically demanding and
how hard a single shift is in the Emergency Department for us all. Even for
the well and able, I think we take it for granted.
It was suggested that I could sit in minor injuries, work with a support
worker and see the ambulatory patients, meaning I wouldn’t have to get up
as much. To me though, that’s not who I am. I was desperate to be back in
Resus, be treated like a ‘normal’ person again and do what I signed up to
do, just like the rest of you.
Needing 12 weeks off work was partly down to the physical logistics
of me getting around. Our department is completely unsuitable for someone
using a wheelchair or crutches (that may not be the case everywhere) and
what is required of a fully functioning junior emergency physician just was
not possible for me.
I couldn’t do CPR, I could only cannulate if I was sitting on a chair, I
couldn’t do most practical procedures or help patients physically, and
standing in awkward places to assess them and write notes left me
exhausted. Therefore when faced with patient volume and time pressures, I
was very inefficient and felt worse about myself and my own (lack of)
abilities.
If you look at the average age of staff in your ED, it is probably
young. Fitness and activity levels are likely to be high, determination and
drive is rife and a lot of people have a similar outlook and flavour for life. I
have all of those thoughts and motivations but often cannot execute them,
and that is a tough pill to swallow.
Do I work part-time through EM training and take nearly 15 years to
strive to be a consultant in my mid-forties? Do I settle for working as a
locum or a staff grade in order to remain in an ED? Do I risk having
extensive periods of time off work when my disease doesn’t allow me to
stay active and well, letting colleagues down on the training rota, and others
in the department?

I have had world-class care and I have also had some poor care, and
these experiences are what help me to be a good doctor to my patients. With
this in mind, I have created a supportive and educational website and social
media page, Rheum For Improvement. It is a positive, evidence-based
platform that aims to inspire and encourage everyone to make the most of
life through hobbies, wellbeing and knowledge of health and food. When I
was told there was nothing more that could be done for my Arthritis
something clicked inside me, and I researched everything I could that had
the potential to make a difference. My findings are what has helped Rheum
For Improvement become more than an idea and whether you have a
chronic illness or not, there is something there for everyone.
4 months later I am back at work, on the least medication I have been
on for decades (albeit a high dose of steroid!), exercising more frequently
than ever, and I am really happy. I truly believe this is down to working on
my mental health and changing certain other aspects of my diet and
lifestyle. Rheum For Improvement shares these experiences and I hope that
through my website we can all learn something for ourselves, and further
help our patients and colleagues.

Can EM training adapt?

So how does EM need to change in order to embrace the needs of
people like me? Doctors often have a preconceived idea of patients with
chronic illnesses and I want to help change this attitude. Equally in the work
place, is it possible to accommodate someone who may not always have the
capacity or the physical capabilities of the desired EM trainee? Adapting a
workplace for a member of staff, when such a high proportion of your
patients have physical limitations should be simple in theory, but I don’t
think that is enough in this specialty. Whose responsibility is it to make
these adaptions anyway – the trust because I work there, the deanery
because they gave me the job, or me personally because I chose this path?
Do EM consultants reach the top because they have been the fittest, the
strongest, and the most resilient? Or do the doctors with illness or difficult
life-situations filter out along the way? A few of my consultant colleagues
and I all agree that it is likely to be the latter, and this is a problem.
None of these questions are easy to answer and considering a change
in specialty is incredibly difficult. I have been told that it is quite novel to
love your job, and I am blessed with that. Emergency Medicine is a unique
specialty and those that are able to do it are very fortunate. I don’t feel I am
giving up or admitting defeat, and I hope that when I apply for my chosen
alternative specialty in a few months, I can show them the same
commitment and enthusiasm that I have done for emergency medicine.
There are lots of questions from this post that I hope will spark some debate
so I hope to write a follow-up post on Rheum For Improvement to discuss
things further.
As for Emergency Medicine, it will always have a special place in my
heart. There really is not much else like it!

vb
Harriet Edwards
www.rheumforimprovement.com
Facebook: Rheum For Improvement
Instagram: @rheumforimprovement

Footnote from Simon – Harriet’s career in EM has been fantastic and

she clearly has the talent, aptitude and ability to be a fine emergency
physician but that probably won’t happen as a result of an inability of the
system to adapt to the needs of a trainee with chronic physical health
problems. In my work as an Associate Dean for HEE I often deal with
trainees who are struggling with illness and in general we do a reasonably
good job in supporting adaptation. However, illness constitutes a range of
conditions and adaptations are complex and should be bespoke. Many
young trainees are physically well and thus mental health issues seem to
predominate. We are getting better at supporting trainees with mental health
issues (but there is still much work to be done). In contrast I don’t see
anywhere near the same number of trainees with physical limitations such
as those Harriet describes. Our training programs and hospitals are (in my
opinion – and I’m not speaking on behalf of HEE) less well equipped to
deal with the longer term, relapsing physical challenges a trainee may face.
Harriet’s experiences have made me really reflect on who gets into EM,
who stays in it and whether there is more we could do to support others
with similar experiences. If we are losing good people then what can we do
differently? Harriet’s story, and I know there are others, has made me really
stop and think about what we can and should do. I hope it makes you stop
and think too.
Chapter 15 Written by Alan Grayson

FUTURE PROOFING UK EMERGENCY MEDICINE

I suspect all Deaneries (locality branches of Health Education England as

they are now known) have their traditions and meetings. In the former NW
post-graduate deanery we have ours. One of these is Calman day. Until this
year it was a combination of ARCPs (annual reviews of competency and
progression) for the CT3 and ST4-6 trainees in Emergency Medicine and a
presentation, and celebration, of trainee research. The research
presentations continued in 2016 and I hear there was some really good stuff,
which I’m sure Rick will be along in a bit to talk about.
But by the time this year’s Calman Day rolled around, ARCPs had been
completed so it was decided by the powers that be to convene panels to deliver
some pastoral care to the trainees. This was a shock to some of the more senior
trainees who were expecting the usual ARCP rigour and grilling. What they got
(in my panel at least) was an opportunity to rant to 2 of us (one of whom was a
TPD – training program director) about problems and difficulties.
This post is a reflection on that day and how UK Emergency Medicine
training is (or isn’t) working in 2016. These thoughts are mine and don’t reflect
the college or even everyone in Virchester (Ed – but the St.Emlyn’s team do
share the majority of them and certainly the themes).
Some common themes emerged that I will explore below, but first some
thoughts from Whitney…..

I believe the children are our future

Teach them well and let them lead the way
Show them all the beauty they possess inside
Give them a sense of pride to make it easier
Curriculum

I would concur that the Royal College of Emergency Medicine (under the
supervision of the GMC) doesn’t seem to make things easy. The EM curriculum
is huge (390 pages). It took me (who regards himself as a Meducationalist) over
a week to read it and I still have to go back (regularly) to check things. It’s
saved on my Google Drive and Adobe DC for those nights when I have really
bad insomnia.
One thing that came through was that trainees felt that trainers didn’t understand
the curriculum and know what the trainees learning requirements were. I would
agree that as adult learners there is a need for proactivity in seeking out WPBAs
and tailoring the requests to the curriculum. However, Educational Supervisors
should be aware of what their responsibilities are, particularly for ACATs and
ESLEs (scroll down to page 14 in the link). Allow me to explain.
This is A CAT. An ACAT is a formative educational tool to assess the
performance of a trainee over time and over a range of patients (maximum 5).
The case notes and management plan should be reviewed and the opinions of the
wider ED team on the performance of the trainee should be sought. It’s mainly a
clinical assessment tool but wider aspects such as patient safety, leadership and
time management can be tested in addition. It is not summative and areas of
concern should be clarified by reflection and further Work Placed Based
Assessments WPBAs.
This is ELSIE. She is an older lady. She has a cat. An ESLE is another EM
assessment tool. It is not ACAT. An ESLE is an extended event of observation in
the workplace across cases. It covers interactions, decision-making, management
and leadership, as well as the trainee’s individual caseload. It is around 3 hours
in length and this comprises 2 hours of observation and then an hour of
formalised feedback using the RCEM tool. It’s validated, designed to test
independent practice and should generate an educational prescription for
development of the trainee. Having used this tool and spoken to others, the
results of such a prolonged period of observation can be surprising in both good
and bad ways.
I acknowledge it’s difficult for educators in the Emergency Department. In
Emergency Medicine we need to know the Foundation Curriculum, the ACCS
curriculum (different significantly from the HST one), the PEM ST3 one (ditto),
the other bit of the ST3 one (ditto), the GPST curriculum (god only knows) as
well as taking care of numerous non-HEE trainees all with individual aspirations,
learning needs and attitudes towards engagement. However one ES cannot know
all these curricula. The only solution that I can see is to parcel up educational
supervision so that some consultants take HSTs, some ACCS, some ST3 etc. It’s
only fair, both to supervisor and for trainee. I acknowledge that this may be
difficult in departments with fewer consultants. And please – recognise the value
that WBPAs can have as teaching and learning tools, if you take the time to
engage with them,

Feedback

The session was for ST3 – 6 EM trainees. ST3 especially is a difficult time for
Emergency Medicine trainees. There is a huge increase in responsibility with the
need to supervise F2 and CT1 trainees as well as the need to manage a caseload
and attend to your own personal development. Several trainees commented upon
the fact that they felt unloved and unsupported. This was true across all locations
for training.
So why has this occurred? Well, ACCS is a 2 year programme that has
EM/Acute med/ICU/Anaesthesia. I’d suggest that the delight of attaining a
training post mitigates against the crap shifts and hard graft of EM and AM in
the first year. Unfortunately (for EM at least), trainees are then released into
anaesthesia where they are usually spending their days (and not
nights/twilights/evenings/weekends that EM and AM need to deal with their
caseload) directly supervised and taught by a consultant anaesthetist. As much as
I love (and have always loved) EM, I cannot deny that the 2 years I spent as an
anaesthetist were deeply seductive because of the training and support I received.
This is true (and possibly more so) today for the current trainees.
I completely understand the brain drain to anaesthesia. It’s a speciality with
variety, controlled risk, good educational structure and a good work-life balance.
EM has one of these (in spades) but a poor Work Life Balance (as a trainee),
risky practice and competent and committed educators who are unfortunately
distracted by pressures such as targets and workload from delivering the
education that we would like to (and I am as guilty of this as all of us are).
So what’s the solution? St Emlyn’s blog has covered feedback extensively and I
hope you are implementing some of our ideas in your Emergency Department.
This will help. Another tool that I try and do (I fail, as we all do, but I’m (very)
trying) is to make a point of going round after the shift to say “thank you” to the
group (as it’s #TeamED) and to individuals. Saying “well done” when something
has been done well is also good, but the feedback from today suggests that this
doesn’t happen as often as it ought to. Be a human. Forget the pressures of the
ED and remember that, quite like Edmund Blackadder, your trainees will follow
you to chaos and uncertainty. Love them and praise them. Take time to
understand them. They are worth it.

We’re in this together

I don’t know what your job plan is, if you are an Emergency Medicine
consultant. I don’t even know what my colleagues’ job plans are (but that’s a
different story entirely). What I do know is that trainees can feel that they are on
their own, with no support, especially when EDs are busy and it’s (significantly)
out of hours. There are many reasons for this. I have blogged elsewhere about
the need for free-range consultants before. I am yet to revisit this, but I suspect
that there has been a (minimal) change over time. The next change comes in
creating vampire consultants who are happy to work in the hours of darkness.
This will not be easy!
Our trainees spend an insane proportion of their lives working in non-plain time.
This comes with the job and only the most naïve would expect to be a 9-5
emergency physician. So why does this automatically change with the award of a
CCT/CESR? (Ed- the certificates at the completion of UK training in emergency
medicine.) As Emergency Physicians we need to look at ourselves, our patient
population and presentations, and our trainees and re-evaluate. I would suggest
that if the predominance of your trainees’ hours are antisocial and without direct
consultant accessibility then you are not going to be able to provide adequate
training.
So what should you do if your Emergency Department is in a parlous state at
8/10/midnight when you are due to leave? Suck it up, you’re paid a shed load of
cash (Consultants, in the UK at least, are 1%ers, like it or not) and help out. You
can see patients quicker, better and with less subsequent problems than any of
your juniors. It’s an investment in not dealing with problems occurring later and
better performance from, and loyalty of, your juniors. No one wants a boss that
they have no respect for. Don’t be that guy. However, if it’s a regular problem,
that’s not sustainable. Manage it. Diarise and renegotiate your job plan.
Negotiation is one of the core skills of an EP. You need to be able to provide
support without killing yourself or your patients through burnout and tiredness.
I’d suggest that if you’re in a department that’s struggling, having the majority of
your consultants doing day shifts is anachronous and poor management. If you
can show your trainees that you are all in it together (Ed – as demonstated in
this video of an Alan Grayson led handover in Virchester) then they are more
likely to join you as consultants in addition to engaging in QI and management
(ie the stuff that takes up all your time), as well as being better doctors.
Rotas

This is a separate blog post in itself. In the short term, ask yourself this: if I was a
trainee, would I think my rota was fair? Can I get study leave or get away to my
best mate’s wedding? If not JFDI and sort it. These are either enshrined in law,
entitlements or just basic human decency. Make the rota decent so that the
juniors aren’t utterly knackered and peri-burnout and their engagement and
performance will be significantly better.
Make sure your trainees monitor. If they are working unpleasant shifts, they
deserve paying for it. A Band 3 rota will make the exec and the BMA take
action. It may not be pleasant, but you reap what you sow. It’s also the law.
Also, publish the rota well in advance. No one appreciates unpredictable shift
changes and a night shift with 2 days notice to organise child care.

Learned helplessness

I would be amongst the first to admit that EM is tough presently. There are
increasingly high numbers through the front door and increasing difficulties in
moving them through the back door. Many trainees mentioned practising
corridor medicine and their discomfort with the associated risk as well as the
lack of apparent solutions from Executive boards.
I doubt that the numbers in will change soon. We have an ageing population that
are sicker and a social care service that seems designed to fail. I could rant about
the underfunding of Public Health but this is an EM blog (Ed – although
arguably we ED clinicians do have a public health role to play!). Apart from by
voting every 5 years, writing to our MP and filling in incident forms when it is
harmful, we cannot control central underfunding. We should be mindful of things
beyond our control; be concerned, be reactive (and proactive), but it’s not worth
having a stroke over. Control that which is within your gift and escalate (and
make sure it’s on the risk register) that which is not.
Trust the triage system. It’s validated. Trust your colleagues. They have good
intentions, even though their skills aren’t comparable to your own. See the sick
patients first. I’d be really sad to go back to the days where a green ?ankle
fracture (likely sprain) waited 12 hours to be seen or left without being seen, but
I, and you, have a responsibility to the sick where time critical interventions are
both lifesaving and saving of time down the line.
It’s no secret that I was a fairly poor medical student. I paid for my degree
working in bars and in kitchens where there was a preponderance of idiots in
charge. One of my favourite books, for its description of the crazy life we lead, is
Kitchen Confidential by Anthony Bourdain. It’s an autobiography of a bloke
who started out well, went wrong and ended up lucky, working in a high end
kitchen in New York. I see amazing parallels with my life (without the major
drug misuse) as the lifestyle of unending pressure, antisocial hours and demand
for perfection are similar if not the same. Bourdain speaks of the pose that
experienced cookies adopt; hunched, guarded, defensive, ready for the next
beating. Sound familiar? The counterpoint to this is the beauty of the teamwork,
the unfailing performance under pressure, the pride in the finished product as
well as the development and education of team members with mentoring,
support and opportunities. I probably took more from it into medicine than I did
from House of God. Have a read.

Conclusion

So what has this been about?

I make no secret of the fact that you should #loveyourtrainees and
#loveyourjuniors. I have no affinity with Whitney Houston, but I do believe that
the children (trainees) are the future and that market forces apply – no trainee
will want to go on to be a consultant in a department if they feel unvalued and
unsupported – they have to work with those unsupportive, exploitative folk for
the next three decades.
You might not even be the best educator in the world or even your trust. I’m not,
by any stretch of the imagination. I do care though, about trainees being valued,
and about being contactable (all of the registrars, my EM trainees that I
educationally supervise and all 96 hospital foundation trainees have my mobile
number and personal email address). This matters, more than you would believe.
If you are a trainee reading this, I’d ask for your time (in HENW all educational
supervisors should get paid for the role). Mutually work out how this will work,
we’re all adults after all.
If you are a trainer, I hope that there’s some inspiration to actually do what you
do best. I know you’ve got clipboard-wallahs pecking your head about breaches
but realistically, the DoH and NHSE have given up on the FHT. WE need to
concentrate on education and quality care and if we were allowed to get on with
that then the targets may fall into place. At least the pressure on Emergency
Department would diminish.
We have the best job in the world. Time to show the world why. We can only
control that which is within our gift and that’s huge.
Thanks for reading.
vb
AliG
Chapter 16 Written by Craig Ferguson

SELF ROSTERING & ANNUALISED HOURS

Introducing self-rostering and annualised hours

Over the last few years, in response to our ever-growing popularity with the
public, the number of consultants at the St.Emlyn’s ED in Virchester has
significantly grown. This, in turn means that the role of the rota-master has
become ever more onerous. The consultant body is composed of individuals
with varying interests and who are at different stages of their careers and
lives. Some people are flexible in their work patterns while others need to
coordinate their shifts months in advance to fit with other commitments of
their work or home life. The pattern of patient attendances has also changed
over time; an increasing proportion of attendances happening outside of
traditional office hours and the shifts worked have had to evolve in
response.
Realising that there was no ‘one size fits all’ approach to this
conundrum, we sought a solution that reduced rota-master responsibility
while increasing the flexibility and autonomy for the individual consultants.
In recognition of these issues we have adopted two distinct but integrated
concepts in our approach to the consultant rota: annualised hours and self-
rostering. This blog explains how they work, the positives (of which there
are many) and some of the downsides too.
Annualised Hours

The concept behind annualised hours is straight forward; Instead of

calculating job hours on a weekly basis, the total number of hours, or for a
UK consultant, programmed activities (PAs), per year is calculated. In line
with RCEM guidelines we used a value of 42 weeks per year as a basis; that
is 52 weeks less the entitled annual leave, study leave, professional leave
and bank holidays
(Ed – note that the study leave and professional leave has to be justified as
per job plan, courses, activities etc). Next, we calculated the weekly number
of pas that any individual worked, for example a consultant may be
contracted for 10 PAs with 2 PAs for clinical administration, teaching and
continued learning. This would mean that they are contracted to work 8 x
42 = 336 clinical PAs per year. We only took account of the direct clinical
care PAs for the purposes of rostering. We work our SPAs flexibly and don’t
roster for these on our ‘clinical roster’.
Self-Rostering

Self-rostering is also a simple concept – calculate how many shifts you

have to work in a year then choose which shifts to work; the mechanics of
how to actually do it were a little trickier. Here at St.Emlyn’s we have over
25 consultants who work in the ED, but that’s made up of all sorts of
different job plans. Some of us work in critical care, some in paediatrics
(some not), some work at one of our linked district general hospitals, some
do pre-hospital care, others are in education, and of course we have our fair
share of clinical directors too etc. This complexity is probably not that
unusual and will be reflected in many emergency departments. We support
this kind of portfolio career as a way of keeping interested and avoiding
burnout. The complexity is a huge bonus individually but it makes the
development of a standard model of what a consultant does impossible.
Similarly the number of individuals involved and everyone’s commitments
and responsibilities meant that a sit-down meeting once a month, or even
once a quarter, was never going to be a practical option. We had to find an
alternative way of ensuring that we had both adaptability and equity without
all being in the same place at the same time to arrange it.
The Practicalities

I thought long and hard about how to actually go about this. A paper wall-
chart is a glitch-free solution that never suffers from network issues but is
limited by the need for physical proximity in order to view or edit it. On-
line solutions involve more than wall space and drawing pins to set up but
at least allow everyone access to the rota from anywhere in the world that
has internet access. It can also provide a log of who, what and when
changes are made in case of any disagreements.
After deciding that the Internet was the future, I looked at several
commercially available software packages, and a few free ones, but I
couldn’t find anything flexible or adaptable enough to fit in with our
idiosyncratic work patterns. UK consultants have contracts based around
Programmed Activities (PAs). A PA is four hours during conventional
working time and three hours in the evenings or at weekends. So if
somebody wished to work a ‘late’ shift, they may start working in
‘standard’ time and work the last hours of their shift in ‘premium’ time.
After much deliberation I settled on creating our own site on Google sheets.
This is a free but powerful spreadsheet software that can be accessed on
almost any desktop, tablet or phone with internet access. Access can be
controlled requiring users to log-in and then the owner can decide if the
users are allowed to edit or just view the sheets. The cells in the spreadsheet
can contain not only data but also formulae; and it’s possible to manipulate
the data using Google script, a relatively simple but powerful form of
computer code based on Java script.
The On-Call Roster

The on-call remained under the control of the rota-master. A rolling roster is
available with several months of on-calls mapped out in advance to
facilitate swaps. All of the other shifts were available for self-rostering
thought there were some limits imposed, for example, how many of each
type of shift were available to be signed up for.
The Master Sheet

The basic concept of the sheet was fairly simple. A Master sheet was used
to set the on-calls and then every consultant on the rota had an individual
page to choose their own shifts. The Master sheet writes the on-calls to the
individuals pages, and the individual pages write the selected shifts to the
Master sheet. Scripts are used in the background to limit the options of each
cell on the spreadsheet page.
I’ve shown a simplified version of this below. The rota-master has assigned
the on-calls for this period and they are visible on everyone’s pages. DocA
decides to sign up for day shifts on Wednesday and Friday.

When DocA looks at his page he can see the on-call schedule. Shifts that
are available to be chosen are labelled as ‘Available’. Clicking on a chosen
cell will provide DocA with the options of selecting his own initials or
leaving it as available. Signing up for a shift is simply a matter of clicking
on that cell. To come out of the shift, DocA can select the same cell again
and is offered a choice of ‘Available’ or ‘DocA’.

DocB may then decide to sign up for a shift on Thursday. When DocB
looks at her page she can see the on-call rota and the available shifts. She
can see the shifts that DocA has chosen but these cells are locked for her.
When DocB selects an available cell she is offered the options of
‘Available’ or ‘DocB’. This allows everyone to see which shifts have been
selected and edit their own choices.
Only the rota masters can edit the eight weeks immediately before the
current date. This allows last-minute swaps or changes but provides a
period of stability before the rota is actually worked. This period of Week
One to Week Eight makes up the ‘Current’ rota page. Weeks Nine to
Sixteen were available for everyone to edit on the ‘Master’ page;
individuals can sign up or sign out of shifts for that period to their heart’s
content. The Archive page shows all the shifts that have taken place and
there is a table that displays totals for all the shifts that everyone on the rota
has completed.
Rolling the Rota

Every weekend, just after midnight on the Sunday night, the magic
happens; a time-triggered script runs that moves everything forwards by one
week. The week that has just passed is dumped on the ‘Archive’ page.
Weeks Two to Seven all move up a slot and Week Nine from the editable
page moves to the bottom of the Current page. The editable page also
moves everything up one notch and a new week Sixteen is generated at the
bottom.
The Weekly Update

I’ve shown a simplified version of the rota here with only three weeks in the
Current section and three weeks in the Future, editable section.

At the end of the week, Week One from the Current rota moves to the
Archive page and the rest of the weeks jump up a block. Week Four from
the Future rota moves to the bottom of the Current Rota and a new week is
generated at the bottom of the Future rota.
On-calls

The on-call shifts are automatically filled in from a separate spreadsheet

page that is written and is available several months in advance. This means
that the next sixteen weeks of the rota are always available to be viewed,
avoiding a quarterly rush to sign up for 13 weeks on one day. The ultra-
organised can sign up for each week as it becomes available and the more
laid-back can let things slip for eight weeks or so and still sign up for their
shifts in time. For people who have to work certain shifts there is an option
to sign up for default shifts that automatically get added to the rota when it
does its weekly update. For example, if you always wanted to do a day-shift
on a Monday, then you could sign up for this on your default week and it
would be automatically be filled in.
Avoiding Over or Under Working

To ensure that everyone has an idea of where they should be up to with their
shifts there are a couple of calculators available. There is one on each
individual’s page that keeps tabs of how many shifts you have signed up for.
There is another calculator related to the Archive page that shows how
many shifts you have actually worked. This calculator also predicts roughly
how many shifts you would be expected to have done by this point in the
year; if you are at that level or above then the number shows up in green, if
you are lagging behind it shows up in red. Simon’s section is shown below.
This shows that at this point in time he has worked 210 PAs, he would have
expected to have worked 205 by this point in the year and he has 18 more
booked into the system at this time. In other words he is slightly ahead of
where he should be, but not by too much. A similar calculation can be made
for all consultants in the department such that we can see whether the entire
team is ahead or behind where they should be at any point in the year.

Annual Leave

Annual leave in an annualised rota works in reverse to a standard rota as

instead of booking your time off, you are booking your time on. Any time
that you are not signed up for a shift is time off (Ed apart from non clinical
DCC and SPA). That said, we still found that we had to take a note of leave
to allow an oversight of when people were available or not so this was
another page on the spreadsheet. Requesting leave on this sheet creates a
time-stamp so it was very clear what was requested and by whom.
Approved leave is then linked to a Google calendar and also appears on the
individuals rota page when the relevant period is on the rota.
Swapping On-call Shifts

On-call swapping has also been automated using another sheet on the rota.
The consultant adds their name to a column, and then completes the date
and the type of shift that they wish to swap. Automated emails can be
generated for the group to ask if anyone could cover it for them. Once
someone agrees to cover the shift then they can add their name to the sheet
and click to confirm; this time-stamps the agreement and generates emails
to the individuals involved confirming the swap and updates the relevant
parts of the rota to confirm the change. Or, swaps can just happen the old-
fashioned way via a corridor conversation and the rota-master can update
the change.
Back Ups
Google makes it easy to make copies of the whole spreadsheet and I did this
several times a year as a form of back-up. I also set up a script to create a
copy of the spreadsheet in the form of a Pdf file that is emailed to myself
and my PA every week on a Sunday just before the update happens. A paper
copy is printed off every week to maintain a hard copy.
The Good Bits

So, what is good about it. The whole thing has been relatively easy to
implement due to my colleagues being open-minded about a new way of
working. Overall the feedback has been overwhelmingly positive.Many of
my colleagues describe it as the best thing we’ve ever done and those that
have moved elsewhere tell us that they really miss the ability to flexibly self
roster.
Other good points are that we have been able to link clinical administration
time to the clinical shifts so that there is a direct correlation; the more
clinical time that you work, the more admin time that you will receive. This
is particularly useful for individuals who work more or less than full-time
equivalent.
The annualised hours have also allowed much greater flexibility. It is no
longer necessary to swap shifts or on-calls, individuals can simply do the
shift and have the associated PAs removed from their pot. This also allows
colleagues who may not be part of the main on-call rota to do the occasional
on-call.
Recently, we were able to provide cover for our junior colleagues during
their recent industrial action by using clinical PAs from our annual pot.
Other departments within our Trust had lengthy debates about how the
consultants would be remunerated for their additional work.
The flexibility has allowed us to easily redo the calculations to take account
of altered job-plans or having new colleagues join our team. And this
flexibility has allowed the introduction of single PA shifts which have
proved very popular. This allows Consultants to attend a meeting in the
morning but still provide a clinical shift in the afternoon or vice versa. It
can also help with child care as it’s easy to arrange a 1PA shift around pick
up or drop off at school. This temporary boost to consultant numbers helps
the department cover meal times, or deal with surges in attendances.
The rota is transparent to all, we can all see what each member of the team
is working, which department they are working in and how close to their
predicted number of shifts they are. This openness and transparency means
that nobody has anything to hide. There is no room here for complaining
that someone else is/isn’t working as hard as you are. We all know what we
are doing and we can see instantly whether it is ‘fair’ or not. It’s a great way
of avoiding disputes about time, location and type of shifts (Ed – you’re
being polite Craig, but we both know that problems can really flare up
around this in other organisations, we just don’t get that as a result of
openness).
We have also seen consultants increase their commitment to out of hours
working using this system. A few years ago we were asked to do more
evening shifts, way beyond what we were contracted to do. We politely
declined the opportunity (there were far fewer of us back then). When self
rostering came in the team recognised that there is flexibility in working
evening shifts AND there is a time premium for doing so. The result is that
we have now effectively doubled our evening and weekend working by
allowing the flexibility of self rostering. This is win:win for everyone. We
get a better work:life balance, the department gets better cover, the juniors
get more support and the team can flex and adjust to what works for
everyone. It’s a great example of how a team that works to an opportunity
(self rostering), will be far more successful than one that is pushed into
change by a threat (the original idea to ‘make’ us work harder).
The Not So Good Bits

What’s bad about it? There was a pretty steep learning curve to get to grips
with using spreadsheets and scripting to set the whole thing up. I’m very
grateful to all the altruistic individuals who populate YouTube with their
videos and patiently respond to queries from ‘noobs’ such as myself on
internet forums.
There were a few glitches and teething problems in the system and I am
grateful to my colleagues for patiently pointing them out. These problems
have become less of an issue as the site has evolved over time and my
understanding of spreadsheet function has blossomed from adding up
columns of numbers to writing scripts that can run automatically.
While I’ve tried to keep the user interface as simple as possible, the system
manages a lot of information from a lot of individuals, meaning that at some
level there has to be a degree of complication. This has meant that someone
with some understanding of the scripting involved has to be available to
deal with any issues that arise.
One major concern with introducing this system was that everyone would
sign up for all their shifts at the beginning of the year and leave the last
three months of the year without any cover. There was an element of this in
the first year but we have largely managed to control this by displaying an
‘expected’ value of shifts on each individual’s page; this lets everyone
know if they are behind or ahead of their expected number for that time of
year. We have also allowed everyone to carry a few shifts over or under.
This new system has failed to resolve certain issues, such as the fact that
there are certain days or weeks that pretty much everyone wants to be off;
for example when major conferences are being held locally. For these issues
and other issues such as the fair distribution of bank holidays we have had
to rely on the altruism and good nature of the consultant body and happily
such an approach has overcome any potential issues.
We are also mindful that we have developed what we think is a fabulous
system for consultants. If it is as good as we think could we, should we and
would we do it for trainees too? That’s a question that has challenged us as
non-consultant rota rules are far more complex. We’d love to hear from
anyone else who has done this in the UK.,
Summary

Overall, I would wholeheartedly recommend using both annualised hours

and self-rostering. The tribulations of introducing this system have been
overwhelmed by the benefits of the flexibility and autonomy it provides.
The roster is clear, easily accessible and it is very easy to work out when
people are working in the future and what shifts they have already
completed. Google spreadsheets have provided an excellent platform for
this system and after the work of setting up the system, it largely runs by
itself with just the occasional adjustment. I really think that we would
struggle to return to the old system.
vb
Craig Ferguson
@doccjf
Chapter 17
THE PODCASTS

The podcasts

The St Emlyn’s Podcast has over 120 episodes that you can download for
free. Visit the site on iTunes or on PodBean and subscribe today. In these
podcasts, Iain Beardsell, Simon Carley, Liz Crowe and Natalie May discuss
many of the wellbeing issues that affect us in emergency care.
 We have provided links to wellbeing related podcasts below. Please listen
and pause to think about how the advice here can improve your life and that of
your patients, colleagues, family and friends.
Final Thoughts Written by Simon Carley
ZEN AND THE ART OF RESUSCITATION

You Are Not Alone

You are not a superhero

We’ve all struggled at times
You cannot pour from an empty cup
We conclude this book with the three thoughts above. At times of stress
it’s easy to look around and think that you are the only one who is
struggling and that everyone else seems to be coping fine. In truth we
all have our challenges and difficult times as we go through our careers.
It’s important that you look after yourself and your colleagues by
recognising that we will all have difficult times. It’s also important that
we build a culture that admits that we are not superhumans who can
cope with everything all of the time.
We hope that this book gives you ideas on how to get the most out of
your life as an acute or emergency clinician. Please share it widely and
let us know if you have found it helpful.
Lastly, remember that the Free Open Access Medical Education
(#FOAMed) is a worldwide community that you can reach out to for
help, advice or just to talk through the tough times and the great times
that define our professional careers.
Chapter 19
ABOUT ST EMLYN’S

The St.Emlyn’s team are an international team of

clinical educators who specialise in emergency
medicine, critical care and prehospital care. St
Emlyn’s is a virtual hospital based in the mythical
town of Virchester.
 You can learn more about St Emlyn’s on the
following links.
Subscribe to the blog
Subscribe to our PODCAST on iTunes
Follow us on twitter @stemlyns
PLEASE Like us on Facebook
Find out more about the St.Emlyn’s team
Come join us at our conference in October 2018
CONTRIBUTORS

Editors
Simon Carley, Professor of Emergency Medicine, Emergency
Department, Manchester Royal Infirmary, Manchester, UK
Laura Howard Specialist Registrar in Emergency Medicine.
Emergency Department, Manchester Royal Infirmary, Manchester, UK

Chapter authors.
Janos Baombe Consultant in Emergency Medicine. Emergency
Department, Manchester Royal Infirmary, Manchester, UK
Laura Howarrd Specialist Registrar in Emergency Medicine.
Emergency Department, Manchester Royal Infirmary, Manchester, UK
Alan Grayson Consultant in Emergency Medicine. Emergency
Department, Manchester Royal Infirmary, Manchester, UK
Natalie May. Ambulance Service New South Wales Rescue
Helicopter Base, New South Wales, Australia
Ross Fisher. Consultant Paediatric Surgeon, Sheffield Childrens’
Hospital, Sheffield, UK
Harriet Edwards, Emergency Physician, Emergency Department,
Manchester Royal Infirmary, Manchester, UK
Craig Ferguson, Specialist Registrar in Emergency Medicine.
Emergency Department, Manchester Royal Infirmary, Manchester, UK
 Liz Crowe, PICU Social Worker, PhD Candidate, School of Medicine,
The University of Queensland, Brisbane Australia
Steve Jones, Consultant in Emergency Medicine. Emergency
Department, Manchester Royal Infirmary, Manchester, UK
GALLERY 19.1 The St Emlyn’s conference

Come join us in Manchester