Inside Queen’s Hospital, Romford, England
“I honestly could have jumped in front of a bus this morning mate,” Matthew McMahon joked to his colleague as he donned his stethoscope around his neck. “But I didn’t so I guess I’m here”.
Matthew had ticked off every part of the job. The invasive procedure to rid someone of plugs of thick slime blocking their airways. Listen for the tell-tale gurgle, feel for the secretions through the chest wall, tilt the head back, insert the plastic airway, you might need to use a bit of force. Keep your glove sterile, pass the catheter down, only three times. You’ll know you’ve hit lung when the patient coughs. Textbook. Simulation dummies in the physiotherapy practical rooms had nothing on a real patient. Despite Matthew’s flawless technique, the patient died later that evening. But it wasn’t her death that hit him. It was that he couldn’t identify how he felt. He knew he was meant to feel something. Grief maybe, he knew that one. Disappointment, he knew that one too. That day, the only feeling he could locate was exhaustion.
The bright artificial lighting belied the grey, English sky outside the medical care ward. Through the window he could just see the hospital’s façade painted a jaunty yellow. A seemingly hapless attempt to soften the brutal architecture. The comforting odour of chlorhexidine and antiseptics battled the smell of his own breath inside his protective mask. Matthew surveyed the ward. Crammed into shared bays lay patients sick enough that they should be ventilated. They needed the brilliantly clever machine to pump in and suck out air from lungs that could no longer carry out their designed function. But there were no ventilators left. No room at the inn.
His ears rang with the hissing of oxygen through cannisters at a rate of 15 litres per minute to non-re-breather masks sitting over patients’ noses and mouths. A mask that allows higher than normal levels of oxygen through it and prevents the patient any wasted breath inhaling their own expired air. The masks were typically used for short-term emergencies. Matthew’s patients had used these masks for up to three days. The machines monitoring the oxygen level in a patients’ blood continuously alarming, screaming, that somebody, anybody vaguely qualified should do something.
As a senior respiratory physiotherapist, Matthew’s job was to wean these patients down from their supplementary oxygen as much as possible – assessing their demand, their capacity, and endurance to even sit on the edge of the bed or stand. How much oxygen they needed to carry out simple, normally trivial human tasks. Managing their movements, keeping their muscles viable. Teaching the patients deep inhalations, position changes, modifying their oxygen delivery masks. And calling their loved ones. “It got so grim,” he said. “We had a roster of who calls the family.”
Hopeful 20-something physiotherapy students shadowed Matthew, soaking up the respiratory techniques he was teaching like the patients did oxygen. They were part of the panoply of allied health professionals littering the hospital. The likes of physiotherapists, speech pathologists, dieticians, occupational therapists; the adjunct therapies that help severely compromised patients recover former function.
They learnt valuable lessons that day. They realised swanning around with a stethoscope wasn’t going to help them know what to do next. They learnt more than how to quickly open a sterile glove packet and don it one handed while eyeballing flashing blue lights on monitors that screamed the patient’s oxygen is dropping.
They saw a daughter eavesdropping on a conversation about her mother not making it through the night. They listened to the long, defeated sigh of Matthew, their senior, as he realised the daughter was behind the curtain. They learnt how gut wrenching it was to put someone through the traumatic experience of having their airways manhandled when it was pointless … as one of the doctors said: “Oh yeh, sorry, she should have been palliative”. They learnt that you don’t torture someone who is about to die, only someone who will survive. They witnessed the slow gnawing away of Matthew’s resolve when he, a natural born fixer, couldn’t fix someone.
Finally, his Groundhog Day was over. He now just had to get through the ten-minute walk to the Transport for London overground station. He knew leaning his head on the window for that 45-minute train ride home would be the best part of his day.
In hindsight, being a physiotherapist trained in ventilator management was an unfortunate career move for someone working in an acute hospital during a global viral disease outbreak. A viral disease which mainly manifests through lung failure but doesn’t follow the normal or predictable pattern of lung failure. He couldn’t put his finger on how he got here. Aside from choosing his university preferences as a 17-year-old based on how he liked being around people and probably wouldn’t enjoy sitting behind a desk all day. In retrospect, he hadn’t much enjoyed doing CPR either.
“I know how I coped; I drank”
According to the World Health Organisation, burnout is a result of chronic workplace stress that has not been successfully managed. “I know how I coped,” Matthew confided. “I drank”. Drank, and endured his own relationship breakdowns.
The symptoms associated with burnout include emotional exhaustion, decreased feelings of personal achievement, poor sleep, cynicism relating to work and workplace-induced anxiety. The most notable feature is an overwhelming and misplaced sense of apathy – apathy where empathy used to lie. Thoughts of “I actually don’t care about your 5/10 pain” and monotone responses of “you need to take a deep breath; I don’t know how much more simply I can say it”.
It’s ironic because being in health care jobs in the first place is usually due to a higher level of compassion and empathy for the fellow man. After repeated, unavoidable engagement with humans at their most vulnerable, empathy then reveals itself to be a necessary but damning trait.
First named by psychologist Herbert Freudenberger in 1974 who described burnout as “particularly pertinent to caring professionals”, it is yet to be reflected in formal university education. “You spent so long telling me about mucociliary clearance and saying the page margins of my assignment were too wide,” Matthew said. “You didn’t tell me how to deal with this s–t”.
Inside Mona Vale Rehabilitation Hospital, Sydney, Australia
In terms of dealing with the fallout of compassion fatigue and her burnout induced eczema, Caitlin Jamieson’s GP had two illuminating suggestions. The two options were methotrexate, your run-of-the-mill immunosuppressant used for a range of cancers and autoimmune disorders, or “maybe just consider a new job”. A clinical dietician calling the sunny Northern Beaches of Sydney home, Caitlin’s community-based education role for Diabetes Australia had left her own health crumbling. The new job at Mona Vale hospital came, and the stress induced eczema went, but the burnout crept back in, just finding more creative ways to manifest.
Mona Vale Hospital basks on a headland boasting its prime coastal position. It ought to be a dream work location, unless you’re one of the staff manning the wards mixed with stroke, orthopaedic and complex aged care patients. The deep blue ocean and the golden sand, a mere 350 metres away, almost taunts those medical ‘prisoners’ unable to make it down the 43 steep steps from the grassy knoll to the beach.
A lean, vivacious, light brunette in her late 20s, Caitlin is the picture of physical health. She’s bubbly and approachable, every second sentence being broken by a giggle, and as the job title would indicate, eats a more well-rounded diet than your average Australian.
Ward rounds begun like clockwork, no hand left without a mug of coffee, as Caitlin reviewed what type of chaos lay ahead of her. Her efforts each day to manage her wellbeing and do all the right things; exercise, eat well, get enough sleep, have a hearty and nutritionally balanced breakfast are all erased the moment she steps a foot in the door. This particular shift, she left at lunch time, declaring the afternoon a sick day. Fatigue crushing her like a weighted vest.
Her job is to optimise people’s health at the most foundational level. This isn’t about prescribing a kale salad instead of a burger to a beachside local and it’s not about getting more pork on your fork. This is about dealing with the sick and dying. Every patient a different, complex equation of biochemistry, medical co-morbidities and their own scepticism of which Caitlin must play puzzle master. “We aren’t just supplement dispensers,” Caitlin vented.
She navigates how to optimise the dietary intake of patients who suddenly can’t talk after suffering a catastrophic stroke or who can no longer swallow. Someone who has no way of telling her how they feel or what they need. She teaches nursing staff how to deliver feeds through a tube inserted directly into the stomach via the nose, all the while looking into the patient’s ambivalent eyes when “you know they are done, you know they’ve had enough of this”.
“The outpatients are almost worse,” Caitlin said. “You have so much more face-to-face time, and food is an incredibly emotional subject, the sessions can be incredibly draining”. The outpatients Caitlin refers to are those people deemed well enough to live at home, but need to return to the hospital weekly, bi-weekly or monthly for ongoing review. Their lives becoming a routine of office hopping between speech pathologist, dieticians, occupational therapists, physiotherapists, in the hopes of returning to a state that vaguely resembles their former selves.
Caitlin had become acclimatised to death; she had learnt to expect it from certain patients. But after spending daily, intense face-to face time with the patients talking about their family, hobbies, beliefs or favourite spot to sit down at the park, their deaths slowly break down the carefully placed professional barriers.
“I didn’t’ want him to die, I wasn’t ready.”
“I didn’t’ want him to die,” Caitlin explained about her long-stay inpatient who unexpectedly passed the day before. “I wasn’t ready… I just kept thinking you can’t die yet, I still have so much to fix, I still have a plan”. Some deaths bounce like water off a duck’s back, and some deaths rattle and reverberate and are taken home, staying front of mind, long after the ‘headspace’ meditation exercise has finished.
The windscreen was blurry behind the veil of tears on her drive home. After a long year dragging herself through the continuous onslaught of overtime, rural travel, apathetic and disengaged patients, doctors undermining her clinical reasoning, she confided to her mum that she had nothing left to give.
“When you’re a sponge for people that are dying, unwell, or unhappy with their situation all day every day, you’re obviously going to reach a point where you break,” she said. The first breaking point was the overwhelming physical symptom of severe eczema. The breaking point now rearing its head through sick days, tears, mutually apathetic consultations and chest-crushing anxiety at work.
Deakin University Psychology Professor Michael Leiter wrote that burnout is an erosion of one’s positive psychological state, as a direct result of prolonged exposure to chronic emotional and interpersonal stressors on the job. He notes that these varied, people-centred roles place a constant demand on the workers of selfless output with an intense amount of direct personal and emotional contact.
Medical and healthcare workforce burnout has been formally measured, recognised and quantified for over 40 years, so why is it that bright-eyed bushy-tailed young allied health professionals are sent into the workforce so ill equipped to deal with their own emotions? Why has it taken a once-in-a-century pandemic for the discussion of workplace emotional destruction to be front and centre?
These encounters with compassion fatigue and burnout seem to be a rite of passage for many allied health professionals, stories from the hospital’s forgotten foot soldiers about their own work-related mental or physical health struggles. These experiences existed before covid-19, escalated to an unfathomable magnitude during covid-19, and will simmer back down to a regular level of disenchantment long after covid-19 has finished dominating every health worker’s consciousness.
“If you’re going to cry, you cry with the patient in the room at the time”
Nicola Binns, a sonographer of 18 years working at Sydney Adventist Hospital, has counselled and watched multiple students leave the field from pressure overload. She advises budding health professionals to constantly debrief and to rely on their colleagues as support resources. “The hard thing with sonography is that it’s all down to you, the pressure can be enormous,” she said.
Nicola wasn’t taught at university the skills for dealing with the pressure associated with diagnostic scanning. She picked these up in her formative scanning years from the chief of sonography himself. In early obstetric scanning where the sonographer is the mouthpiece for the neonate’s heartbeat, there’s not much that can be done to reassure an expectant mum of a good reason why she can’t hear the rapid murmur of the baby’s heartbeat. “The patients aren’t silly; they know when something’s wrong,” Nicola said. “If you’re going to cry, you cry with the patient in the room at the time.”
For many, the health care system goes on functioning the way it does, resting on the backs of health care workers who have lost their capacity to care or cannot control the scope of their emotions. Relying on the promise of a never-ending conveyer belt of young enthusiastic graduates to fill the weathered shoes of cynical seniors. Watching the endless stream of new, fresh, emotionally intact staff slowly but surely erode unaided from the same sustained exposure to human suffering.
“To be honest, I don’t think I have ever really figured out how to manage this better,” revealed Nicola. “You just start to realise you can’t bring it through the door at home. You have to put it down and move on.”