Question 18

College Answer

The key points that the candidate needs to cover are:

1.  Facilitating the initial critical incident debrief of the Registrar and allowing him/her to vent and tell his/her version of events

2.  Ensuring there is ongoing psychological and emotional support for the Registrar
a.   Give him/her the option of standing down for the rest of the shift or providing support if he/she chooses to stay
b.   Arranging a mentor within the department (eg SOT)
c.   Ensuring there is back-up from friends/family at home d.   Offering professional counselling

3.  Providing advice on the medico-legal process that will ensue a.   Open disclosure with family
b.   Need for comprehensive and accurate documentation in records and factual account for registrar’s own records
c.   Early contact with medical defence organisation and hospital medico-legal advisors
d.   Reporting to coroner if/when the patient dies
e.   The event will be the subject of a Root Cause Analysis by the hospital

4.  Counselling with regards to future career and training

5.  Arrange follow-up meeting with mentor and departmental head for next day

Discussion

• Ensure the critical incident is being managed appropriately from a medical standpoint
  • Commit staff to ensure the patient is safe 
  • Ensure appropriate steps are being taken to ameliorate the risk from the critical incident (for example, if this is a line that has been accidentally inserted into a carotid artery causing a stoke - ensure that the vascular surgical team, neurology team and neurosurgerical team have been consulted and have offered their opinions).
  • Delegate clinical duties so as to focus yourself on the debriefing session
• Critical incident debrief (management of the traumatised trainee)
  • The debrief should happen before the affected person has had time to sleep.
  • Introduce the process
  • Describe the event, using whatever factual information is available
  • Allow the trainee (or whatever participants) to describe their cognitive and emotional reactions to the event
  • Help the trainee identify the most traumatic aspect of the event for them
  • Help the trainee identify personal symptoms of distress and explore their emotional reaction to the event, assuring them that their reactions are normal.
  • Educate the trainee regarding normal reactions and adaptive coping mechanisms, helping them find a "cognitive anchor". Adaptive reaction suggestions may include advice on rest, talking to one's friends and family, working with supervisors to initiate procedural changes, dealing with stress through exercise and reflection, etc. This helps the trainee transition back to a cognitive level domain, away from the emotional content of the experience.
  • Clarify any ambiguities and arrange a follow-up discussion, to ensure that this debrief does not seem like a stand-alone measure but rather a part of a continuum. In a group session, this phase would end with final statemwents from the participants.
• Other management of the staff involved:
  • Organise time off work for the trainee, if appropriate
  • Involve an impartial mentor
  • Ensure that there are support people available from the extraclinical environment (friends, family)
  • Make an offer of professional counselling
  • Give advice regarding open disclosure process and medicolegal risk
• Management of the affected patient and family
  • Clinician open disclosure 
  • Commencement of a formal open disclosure process
  • Discuss the need to refer to the coroner (if relevant)
• Management of the organisation
  • Factual and detailed documentation
  • Inform the clinical governance administrators
  • Inform the hospital medicolegal team
  • Inform the director of the department
  • Inform own medicolegal indemnity and defence organisation - as you were supposed to be supervising that trainee, and may even be responsible for the training program locally (if you happen to be the SOT).

International Critical Incident Stress Foundation

CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010

Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.

Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups." Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.

Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.

Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing." Journal of Loss &Trauma 7.3 (2002): 223-238.

Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.