Stress and PTSD in Perfusion and ECMO
I am fat. Not only that, but I have a lot of health problems as well; diabetes, sleep apnea, hypertension, hyperlipidemia, kidney stones; all comprising the full range of the “metabolic syndrome”. How did I get this way? The change was very gradual over 40 years. I tried to deal with the weight gain, but I always hated exercise. Since I was in my 20’s my lower back had been painful. Exercise was always a trade off. Things like jogging, treadmills, exercise bikes, weight training and even just distance walking were good for my health but killed my back. I was never able to maintain any consistent exercise habits because the back pain eventually became intolerable.
It wasn’t until I retired that I understood how my problems developed. Primarily it was due to “stress eating”. People deal with stress in many ways, both good and bad. Some people hit a punching bag. Others focus on a hobby. Others abuse their spouse and kids. Others turn to alcohol or drugs. Others just quit their job and drop out of their responsibilities. The funny thing is they often don’t realize that their behavior is due to their stress. I always liked foods that were generally bad for me. I think the comfort that I derived from eating the bad food took the edge off my stress, like a drug. In that way I was lucky. If I had turned to alcohol or spousal abuse my life would probably have been very different.
How do I know that I was stress eating? About a year after retiring my appetite greatly diminished. Bad foods that I used to like didn’t seem so appealing. My wife noted that I was not eating as much. But I felt fine, nonetheless. And I have gradually started to lose weight.
As a perfusionist, I was always just a little bit afraid every time I sat behind the pump. I was anxious that, despite my years of experience, a problem could develop with which I did not know how to deal. A little anxiety is a good thing; it sharpens the senses and the wits. But too much anxiety can paralyze thinking and actions. My earliest experiences as a perfusionist implanted into me an obsession with safety. I have written about some of these experiences before, so I won’t delve into them now. But rather than being traumatized, I channeled my efforts to develop safety methods to prevent these problems from ever happening again. So, in this regard, the stress had a good result.
After I became a chief perfusionist and my staff grew in size, I felt a little anxiety every time one of my staffers started a case. Certainly, I was always concerned about patient safety. But I was just as concerned about my staffer being traumatized as a result of an incident. I looked for a way to convey my years of experience to my staff. Many years later when I read the 2004 Wehrli-Veit, Riley and Austin article, I realized that I had found a tool to store experience so that others could benefit. The tool is the Failure Modes and Effects Analysis (FMEA). I have also written extensively about FMEAs and perfusion safety. So I won’t elaborate on them here except to say that when I was editing the FMEAs for Perflist posting, one of the reviewers, Bob Groom, suggested that I include post-traumatic stress disorder (PTSD) counseling as one of the possible management interventions on certain critical failures. He witnessed a severe case of PTSD in one of his staffers after a perfusion incident that eventually caused her to leave the perfusion profession entirely.
I, too, had witnessed the destruction of a career by PTSD. My friend was a pediatric cardiac anesthesiologist with whom I had initially worked when she was in her residency and for more than 10 years as a staff anesthesiologist. We worked together on many difficult cardiac and trauma cases. Then one day she was called into a room as a back-up for a case that had started badly when the patient had cardiac arrest on induction. The code did not go well. This doctor was the only one free to report to the family. In all her years of experience she had never had to liaison between the family and a resuscitation team. This would be her first experience. She went to talk to the parents and family several times. They were inconsolable; blaming the doctors, the hospital and themselves for bringing their child in for surgery. Finally, when my friend had to tell the family that their child was dead, there was no reasoning with them. They became almost violent in their grief, lashing out at my friend as if she were personally responsible for their child’s death.
From that time on I noticed a definite change in my friend’s demeanor. She became sad and very quiet, almost uncommunicative, speaking only when necessary. Several months later, while presenting at a hospital Grand Rounds, she took the opportunity to tell everyone that she was resigning her position and leaving her career as a pediatric anesthesiologist due to the incident. Despite counseling, the episode had so traumatized her that she rarely slept and when she did sleep she had nightmares about the incident. Every time she had put a child to sleep for surgery since the incident, she was filled with great anxiety, fear and self-doubt. This was coming from someone who had always demonstrated confidence and the highest skill during many, many difficult cases. Not only that, she had great strength of character and was not easily intimidated, even by abusive surgeons. I wouldn’t hesitate to let her care for any of my own children. As I spoke to her later, I asked if she was just burnt out with work. No, that wasn’t it. It was the emotional trauma from just that one case that destroyed her confidence and put real fear into her. The good news is that I saw her several months later. She had gotten a job in hospice where she could use her pain management skills to alleviate the suffering of many patients. She smiled at me and said she was happy now; no more nightmares.
Remembering my early experiences and my anesthesiologist friend, I felt stressed worrying about patients AND perfusionists, both. I realized that a major incident on bypass could ruin two lives; the patient’s and the perfusionist’s. With the advent of our ECMO program in 1986 my stress level took an exponential leap. It was my job to train about 30 ICU RNs to “sit the pump”, handling the hour-by-hour monitoring and routine tasks that are needed when running an ECMO circuit. Whenever we had a child on ECMO I worried constantly; not just that the child might die, but that one of the ICU RNs would be involved in a pump incident that injured or killed the patient and traumatized the nurse. I trained the nurses to the best of my ability in the short time allowed for such things. This training didn’t nearly approach the degree of training received in a recognized perfusion school, but I tried my best. I provided training about the circuit failures that the nurses were likely to encounter and what they could do about them. In addition, I and my perfusion staffers were always available on call and we rounded twice a day, once on each shift. I encouraged the nurses to call me or the perfusionist on call if they ever had a question or problem. I made it a point to treat their concerns seriously, no matter how trivial they might seem to a trained perfusionist, even sometimes driving to the hospital in the middle of the night just to reassure them. Was I coddling them? I don’t think so, because I had seen how competent and emotionally strong heath care providers could be traumatized. I was active as a leader in the ECMO program for over 26 years (approximately 130,000 hours on pump). During that time we did have a few incidents involving nurses who became stressed enough that they voluntarily left the ECMO team. Fortunately, they continued as ICU RNs; not leaving their careers.
An outsider might ask why I continued my career if the stress was so bad. My answer would be twofold. First I did not recognize the stress for what it was. When healthcare workers choose to work in a critical area like heart surgery or intensive care, they understand that they are working “under pressure” because of the life and death outcomes. It is just an accepted part of the job. Secondly, I loved the job. Pitting my knowledge and skills against the grim reaper and winning (usually) is a tremendously rewarding challenge. The melodrama of a novel, movie, TV show, video game, or stage play doesn’t hold a candle to the real life and death drama experienced by perfusionists every day.
So what advice can I offer? Not much, I am afraid. If you or someone close to you recognizes that you are using harmful or unhealthy coping skills, perhaps you can make a beneficial change before the harm becomes irreversible. If you experience a severe incident that results in PTSD, I hope that counseling is available and helpful. Often it is not, unfortunately. Otherwise, try to focus on making perfusion safer for patients and other perfusionists. Doing so may help to assuage your anxiety and fear.