Dr Andrew Weeks, consultant obstetrician, discusses the risk of post-traumatic stress disorder (PTSD) in members and trainees that witness traumatic events while working in healthcare, and the need to adequately support these colleagues.
With thanks to input from Laura Goodfellow, Kayleigh Sheen and Pauline Slade
Content note: Please be aware this post includes an account of a traumatic birth.
I remember once diagnosing a stillbirth on an emergency scan. I’d been a registrar for some years and this was not the first or the last stillbirth that I’d diagnose. I’d mostly managed to keep a professional distance, but this mother’s response of piercing screams of anguish and heartbreak filled the corridors of delivery suite and distressed me deeply. A common clinical scenario made uncommon by my emotional reaction.
Each of us who work in health care have our own stories of trauma.
The following story was recounted by a trainee:
‘On my night shift a few years back, a woman was having a vaginal birth after a previous caesarean. Her labour had been uncomplicated until, after 20 minutes of pushing, the fetal heart rate monitor suddenly became very abnormal. I performed an assisted delivery and the baby was born in good condition.
‘But immediately after the birth, the mother started bleeding very heavily. I performed the usual interventions for postpartum haemorrhage, but the blood kept coming and we had to call the consultant in from home.
‘All the time I was working to stop the bleeding, I was questioning myself: did I cause the bleeding? Did I somehow make a mistake with the delivery? Should I have done a caesarean instead?
‘As we pushed the bed to theatre we couldn’t hide the enormous puddle of her blood from her horrified partner. During the examination under anaesthetic the blood kept coming and we identified a uterine rupture.
‘After the eventual hysterectomy, the consultant yelled at me, “Why didn’t you recognise the rupture sooner?” Although she eventually recovered, I drove home after my shift finished, genuinely thinking I might have killed her.’
Sometimes the events are dramatic and unusual, but others are common situations which somehow manage to penetrate our protective emotional armour.
The lasting impact of trauma
In psychological terms, a traumatic event is when we experience a sense of intense fear, helplessness or horror in response to seeing someone in danger of serious injury or death. Most of us will face something like this at some stage of our career.
In the INDIGO survey of RCOG members and trainees, two thirds of people (67%) reported having experienced at least one of these traumatic events.1
In response, the majority will slowly process the event and move on. But a significant minority will continue to be haunted by the event.
In the study, 18% of respondents reported clinical symptoms of post-traumatic stress disorder (PTSD) such as repeated reliving of the experiences or nightmares about the events, trying to avoid any reminders and feeling constantly on edge and under threat.
A further 13% reported still experiencing some but not all of these features.
The tragedy is not only for the obstetricians themselves – it has multiple effects on other aspects of life and work.
Those with PTSD have lower job satisfaction, with emotional exhaustion, burnout and depersonalisation of care. Many consider changing job, or leave the profession entirely.
The scale of the problem makes it clear that something has to be done.
How we are addressing PTSD prevention and treatment
Following on from the survey, the INDIGO team have worked with the RCOG ‘Supporting our Doctors’ committee, and are developing joint Good Practice Paper with the RCOG and Royal College of Midwives. The recommendations will cover both PTSD prevention and treatment.
Prevention requires a change in hospital culture: the development of general understanding about how trauma responses can develop, raising of awareness amongst colleagues so that they don’t exacerbate the problem (as was frequently seen in the INDIGO interviews), and making support easily available for those who experience trauma.
But PTSD cannot be always prevented, and when it occurs it needs to be rapidly diagnosed and then treated with either cognitive behavioural therapy or eye movement desensitization and reprocessing (EMDR) therapy.
We can never stop doctors being exposed to traumatic events – indeed part of our role in society is to take on this burden.
However, as a community, we have a duty to each other and to our patients to support colleagues who experience trauma, and to provide rapid effective treatment for those who subsequently develop PTSD.
Healthcare providers are now recognising the importance of the problem, and this is the first step to reducing it.
Personal help
Please remember that if it gets too much, then help is always at hand. As well as your local line management, please see our Wellbeing resources hub.
NHS mental health support is available at https://people.nhs.uk/.
[1] Slade P, Balling K, Sheen K, Rymer J, Goodfellow L, Spiby H, Weeks A. Work-related post-traumatic stress symptoms in obstetricians and gynaecologists: findings from INDIGO a mixed methods study with a cross–sectional survey and in-depth interviews. BJOG. 2020 Apr;127(5):600-608.