My best and worst supervisors

‘It was as if I had just walked onto an elevated stage and the audience were waiting for me.’

Clinical supervision is difficult. Yet it’s effect on the trainee can be immeasurable.

My Worst Supervisor

I would like to share a story with you all.

This was a traumatic event that ended with the death of a patient and a traumatised team of doctors and nurses.

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I was a very junior emergency registrar at the time working in an urban emergency department.  Like all good stories, this one occurred at 3am. I was in charge of the department. I was full of anxiety and nervous energy on what was the first run of night shifts in my career where I was the most senior doctor in the department. As you might imagine, or remember from your own experience, this was a terrifying time. What is about to turn up in the ambulance bay? What if I haven’t seen this presentation before? What if I make a mistake? What if it is a sick child? What if a patient dies? What if a child dies?

With me I had two excellent British-trained resident doctors and an intern. There was also a compliment of highly skilled nursing staff.

Dr B was the emergency physician on call that night. Nobody liked him. During day shifts he made himself unavailable for assistance and was usually unhelpful. I have never met any clinician less approachable than him. This feeling wasn’t unique to myself. In fact, I was kind of intrigued by his weird introverted personality. As a learned behaviour, junior doctors and nurses wouldn’t bother with him and would turn to somebody else for assistance. 

I didn’t have that luxury at 3am. Dr B was on call.

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The clinical details of the case are not so important to the story in the context of supervision. However, as you may be curious I will summarise here.

The patient was a woman in her mid-forties. She lived at home with her husband and two small children. She had a history of obesity but was otherwise healthy. Over the past week, she had been treated by her GP for an upper respiratory tract infection with antibiotics. She had a productive cough, fevers and breathlessness. An ambulance was called to her home that night because she had worsening breathlessness and fevers. The diagnosis was a respiratory tract infection.

When she arrived at 3am she was confused and agitated, hypoxic (SpO2 88% on 15L non-rebreather mask), febrile (38) and tachycardic (140bpm). Her blood pressure was normal. Clinical examination was difficult and bordering impossible beyond her general appearance and vital signs as the patient would fight against us. We could hardly get a blood pressure cuff on her arm. 

I recognised very early on that this patient had a life-threatening illness. I had the skills to initially resuscitate this patient, I could initiate non-invaseive mechanical ventilation and intubate if I needed. I could sedate her to be able to manage the agitation and gain control. But as a junior registrar, I didn‘t have the experience at that stage of seeing many patients like her. So I did what most trainees would do, call for help. Okay, who was on call. Oh damn, it’s Dr B. 

So I woke Dr B, told him about the patient, told him what my initial resuscitation plan was and requested that he attend the department urgently. He was 25 minutes away.

In that time I was able to stabilise the patient. That involved a dissociative sedation which made everything easier. I was able to further examine the patient which revealed some basal lung crackles and oxygenate the patient with non-invasive ventilation. A CXR showed bilateral pulmonary consolidation and an arterial line was placed. Her ABG was remarkably normal except for the relative hypoxia and a mild lactate rise. A decision was made to delay intubation until the consultant arrived.

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Dr B walked in. The patient was doing better than on arrival after the above measures however the sedation wore off and she soon became hypoxic and confused again. I handed the team leadership role onto Dr B and the decision to intubate the patient was made. Even in hindsight, an appropriate induction regime was determined and an RSI performed. As I passed the tube through her vocal tubes I confirmed the correct position. The airway nurse and I shared a nod of “well done”. And then she arrested...

We performed CPR and standard ALS for the next forty minutes. Dr B was not trained in echocardiography and at that stage of my training neither was I. All reversible causes were considered but no further treatment was indicated. ECMO was not an option. I even suggested thrombolysis, but we weren’t convinced that this would helpful.

The patient’s husband was brought into the resuscitation cubicle. We explained that there was nothing further we could do. Through tears he kissed his wife goodbye and we stopped CPR. The patient was dead. Other than the husband in shock and grief, everything was still.

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Dr B left the cubicle, wrote a quick note at his computer and then went home. He left behind a department that had just had an unexpected and traumatic death. The intern had never seen a death before, two residents who were shaken up, myself who was only just managing to hold it together, nursing staff in tears... and a department full of other patients including those in the waiting room who were yet to be seen and had now been waiting for hours due to the resuscitation. He left without a single word to any of us.

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I only worked in that department for another two months, and never was there any debrief with Dr B. Not at 4am, not the following day. Not at all over the next few months. This was a spectacular failure.

Did I do something that resulted in a patient’s death? Could I have done something better? Anything? What on earth just happened? There is a forty year old woman who has just died and on her way to the coroner’s court. There are two children about to wake up to hear that their mother won’t be there anymore. What did I do wrong? Maybe emergency medicine isn’t for me? The self-doubt and questions continued.

I was fortunate to have other mentors and the support of the department. I didn’t do anything wrong. None of my treatments killed this woman. This woman was critically unwell and the decision to intubate was the correct one. The drugs used for induction were appropriate. The pre-intubation preparation was appropriate. Perhaps if I had echocardiography skills at the time I would have picked up right heart strain. The coroner determined her cause of death to be a massive saddle pulmonary embolism. Perhaps I would have used graded assertiveness for thrombolysis if I had a higher suspicion of PE. Perhaps it wouldn’t have made any difference and she was going to die regardless.

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I raise this case for a few reasons.

I don’t do so to lament Dr B despite his shortcomings. I don’t know what he was going through. I don’t know how he dealt with this death but I do hope he had support.

I learnt a lot about clinical supervision and being a senior doctor that night that influences how I supervise junior colleagues.

• I like to feel that I am always approachable. Irrespective of day or night, busy or not, there is always time for the my colleagues. Sometimes just to listen. 

• Debriefing challenging cases with both good and bad outcomes is so important. Is is not optional, it is essential. There are many ways to do this. Walking away and never speaking about it is not one. 

So think to yourselves:

1.     As a supervisor, how do you make yourself approachable? 

2.    How do you debrief a team after a traumatic event?

3.    How do you supervise and support your trainees when they take a large step into a role of greater responsibility? 

My Best Supervisor

This story was also traumatic. It also involved a death.

This occurred in a different hospital to the above story. This story began at about 2pm. I was a mid-level registrar by this stage, several years after the first story.

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A code blue was called overhead to a stairwell in a non-clinical building. One of those buildings that you know exists but never have any need to venture into. As the registrar responsible for resuscitation that day I left with one of the ED nurses and our equipment to try and find the code blue. Almost every code blue that is not in the inpatient building is not an arrest. Usually it is a visitor who is feeling dizzy, or someone who slipped on spilt coffee in the cafe.

We got there quickly. There was no patient to be found. Anywhere. By now, everybody who attends the code was there. Searching but not finding. Eventually I was in the stairwell and I looked out a small window and I saw him. He was outside. Lying on a balcony ledge between air conditioning units half a floor below. He wasn’t moving.  My heart sank. This wasn’t the someone slipping on coffee or a visitor with dizziness. This was a real code. And I was stuck in a stairwell.

With force, I managed to lever the window to open it and climb down to the balcony. As I made my way towards the patient I looked up. There were people in opposite buildings staring down. There were people at street level looking up. It was as if I had just walked onto an elevated stage and the audience were waiting for me. Except this wasn’t a performance. These people had just been witness to the person climb out of a window many floors up and fall.

I instructed our nurse to call for help as I assessed the patient. That call went to one of the ED consultants, Dr S who came with another nurse and would be about five minutes to reach us. The patient was pulseless and not breathing.  He was in cardiac arrest, likely secondary to trauma. I team-led a remarkable group of individuals, all out of their comfort zone, in a trauma situation on a rooftop balcony wedged between air conditioning units. In a way, the presence of a window and difficult access meant I could only have the most essential people on the balcony at any one time. Oh, and the large audience in the galleries above and below the balcony watching on. That window actually helped control the chaos.

We performed bilateral chest decompression, intubation, fluid boluses were all done, and conventional ALS - all were unsuccessful. Dr S arrived during these procedures and I handed over the clinical leadership to him. We continued for another ten minutes but it was clear that we had no interventions that could reverse the traumatic arrest in the patient. 

We stopped CPR and everyone paused for a moment. I looked up again, the ‘audience’ were still there. They too, were still.

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It was the way Dr S handled the aftermath which contrasts so well to the first story.

Dr S, myself, the ED nurses and the anaesthetist have been trained in dealing with crisis situations. It is still shocking, but we have some tools to manage this. The rest of team may not have been so well equipped and this must have been most confronting.

Every person that was present wrote down their name on a piece of paper. I understand that Dr S followed up individually with every single person on that list over the next 24 hours just to ‘check in’ and ask how they were doing. He organised a hot debrief, a larger hospital wide debrief given the circumstances, and a debrief a few days later where he invited every person on that list. Most turned up. And he then ran a debrief session with assistance of peer support workers to help answer questions that people had - most of what he did was listen to everybody speak, and gently guide discussion. In the decade since, my memory of the content of this session is now blurred. But I do remember how I felt. I felt thanked, I felt that my work was worthwhile, and that I had done a good job. I felt that I was part of a team.

He organised a separate ‘clinical’ debrief with myself to discuss my clinical role and management of this patient. I learnt a lot and this case resonates with me still today. Undoubtably, in similar situations I am a better clinician for this experience.

In my opinion, Dr S displayed some excellent clinical supervision and leadership. There was genuine care for myself and for the rest of the team. He gave us the opportunity to seek out learning points from a difficult case and made our contribution to the care of the patient feel worthwhile - even though there was nothing that could have been done to save the man’s life once he left that window. Some time later I found out that Dr S knew the deceased patient. He knew at the time but didn’t announce this. His focus was on the wellbeing of his team. I sincerely hope that at the time he also had the opportunity to debrief.

I still work with Dr S. Today, he remains a very inspiring colleague.

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I ask you to compare the post-event response of Dr B and Dr S. Who do you aspire to be like?

I ask you to reflect on cases through your career and find the learning opportunities. As you can see, these cases have sat with me for a long time and I am a better clinician for it.