Thursday, 20 April 2017

Suicide

Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving but drowning.

Poor chap, he always loved larking
And now he’s dead
It must have been too cold for him his heart gave way,
They said.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life
And not waving but drowning.

Stevie Smith


I attended funeral about 3 months ago. A family member who killed themselves.

The dogs, frantic through the night, found him first, then his son. Just imagine.

We stood in the rain, a community of working people, heads bowed, in suits too big or too small, around a fresh grave with hot tears.

He wasn't a strange man, or a desperate man. Just a man lost in day to day banality and finally lost in his mind.

And I was angry. Not with him, with him I felt nothing but an aching pity I couldn't have reached out to him at that unGodly desolate hour and given him peace, but with the people who said "I'm not surprised."

"I'm not surprised!?" Because you saw the mental and physical deterioration that resulted in such a violent and tragic end when you could have stepped in?

"I'm not surprised" because of the situation or the work, his position or the circumstances he found himself in?

"I'm not surprised" because it's considered normal for a hard working man in a stressful and lonely position to take his own life and allow his family to find his bloody remains mixed with a muddy yard?

I'm still angry.

Then I received news a couple of days ago about a vet I taught. Dr K God bless you. He ended his life.

Also alone, in some dark place he could only find one way of escaping.

I recall him as a jolly person, always willing to participate. I don't know what happened, only that he was found alone. He was buried this morning surrounded by a huge number of people.

A few weeks ago I lectured at SEVA and was lucky enough to be invited to the evening dinner where I sat with several final year students. One lady I spoke with carried the nervousness I could only ascribe to social anxiety and the excema on her forearms and tic of trying to conceal her scratching belied something I feared may become more ugly with the exposure a young graduate is faced with from day one and which only grows with increasing responsibility.

I spoke with her for little more than 45 minutes but slept fitfully that night wondering what my duty as a fellow colleague should be, or whether my observations were aberrant and even offensive?
I've always been astounded by the trail of tragedy that follows veterinary medicine in its literal wake. Depression, alcoholism, family break ups, injury and suicide. It is so common place that it is met with the "I'm not surprised" dismissive and idiotic "the show must go on."

If anyone is reading this and is in that place. The place where your thoughts are not your own, where the next day envelopes you in fear, where the need to escape may trickle in ideas of death. We know that it hurts, that you are not alone and that at last help is there. In Vetlife, in MindMatters, in the Samaritans, in AA, in a call to a colleague or a friend, on a knock on the door of a neighbor. I only ask and beg that you never allow anyone to utter the words "I'm not surprised."

If you need to talk to someone, Vetlife Helpline is avaialble 24 hours a day. Call: 0303 040 2551 or email via the website: http://www.vetlife.org.uk

Ben Sturgeon

Monday, 3 April 2017

A reply to Booze

I am really surprised at how few responses there are to this blog. Yes, it is about alcohol, but it is also about the need we equine vets have for support and compassion from both within and outside the profession.


Thank you to the author of the blog for sharing your story, which is painful to read, and no doubt worse to be part of. I’m sure that you are a good equine vet – and certainly good enough - because you obviously care very much about your patients, clients and professional standing.


What is it that is missing from the veterinary profession that makes this is such a common story? I know others who did not manage to extricate themselves from the downward spiral and ultimately paid with their lives. Depression, loneliness, isolation and then liver failure. Sadly, far from being supported, they were actually ridiculed and left to struggle alone.


Most of us want to be the best we can be and strive to achieve this. Unfortunately in too many practices there seems to be an element of competition rather than collaboration between individual vets. I was lucky enough to realise that there were times when I needed to bounce ideas off a colleague or receive specialist advice so we developed a network of friends who had expertise in different areas and we could phone for advice at any time. So often all it takes is a 2-minute phone call in a moment of uncertainty to allow one to proceed with confidence. Caring and sharing with a few moments of one’s time . . .


Things don’t always go perfectly and our work is never over as there is always the next difficult case. Thankfully the profession is recognising the importance of looking after mental health with its increasing programme of ‘mindfulness’. But awareness and empathy have to come from within practices. Could it be that with the corporate ‘takeover’ vets will have time to look after each other? Perhaps the remaining independent practices will consider this a priority. Thirty four years in equine practice has been a privilege and at the age of 60 I am not planning to retire. If I had my time again I would not change my career path but it would have been nice to have more support at times along the way.

Sue Devereux

Friday, 10 March 2017

Is work killing you and your patients?

Irrespective of disease presentation and progression the ability of a clinician to make an accurate diagnosis and implement appropriate treatment is paramount in outcomes and prognosis. Most veterinary work requires out of hours work or shift patterns and the equine veterinary surgeon is arguably most likely to experience and undertake a multiplicity.

Our photo-periodic health or circadian rhythms are entrained by the paired suprachiasmatic nuclei (SCN) of the anterior hypothalamus which regulate a host of diverse physiologic processes from sleep, behavioural activity and appetite, through to hormone and steroid production and function, hepatic activity and renal excretion. Interference of these rhythms are associated with many pathological conditions; simple disturbances of sleep or in sleep quality results in excessive daytime sleepiness is referred to as “chrono-fatigue” or “Shift Maladaptation Syndrome,” however, increasingly more significant conditions such as cancer, metabolic syndrome, cardiovascular disease, diabetes, depression, arthritis and asthma have been recognised. The effect of shift or night work has been demonstrated for example, to effect gene expression at the level of the SCN and influences release of various hormones, protein products and cytokines. To take mental illness as an example; chronic stress as experienced by emergency or regular night work has been shown to reduce Brain Derived Neurotrophic Factor (BDNF), which provides feedback from the periphery to the SCN, and a link between chronic stress and BDNF levels with anxiety and depression in people has been demonstrated . Whilst the incidence of cancer among veterinary surgeons in general is unknown, the incidence of depression and mental disorders is above national averages.

Furthermore and importantly, to improve the clinical prognosis of any patient, the ability of the clinician, especially those where work is out-with normal hours, and almost by definition of a stressful nature, to maintain objective and rational cognitive decisions is vital in allowing correct diagnosis, implementation of appropriate therapy and avoidance of medical error. Unsurprisingly, cognitive function is most efficient when well rested. Whilst fatigue can occur independently of sleep deprivation, for example during high stress periods; it often arises due to the nature of equine veterinary work and can lead to error. Diagnostic error can be categorized into 3 major groupings: no-fault, systemic and cognitive. No fault errors occur when disease is silent or atypical, systemic errors are attributed to system failures but it is in the human-factors and individual characteristics influencing cognitive and affective behaviour and decision making that is most influenced by day/night influence or chronobiology. Under conditions of stress, including fatigue, the manner in which a clinician differentiates and implements diagnostic or therapeutic protocols depends and is determined by a variety of factors and it is the summation of these factors which leads, hopefully, to one or a limited number of cognitive dispositions to respond (CDRs) and a diagnostic and therapeutic protocol (Figure 1).

Image

Figure 1: CDR determining factors and actions. From Henriksen et al (2005). Advances in Patient Safety: From Research to Implementation 

As highlighted there are a number of determinants of CDRs but they largely fall into 3 groupings: ambient conditions, past experience and impact of affective state, and arguably all three can be influenced by chronobiology. For example; temperature, activity level, motivation and other variables that may affect clinical performance are influenced by diurnal phase in many individuals. Premenopausal women may be subject to infradian mood variations, circannual influences such as winter darkness can exert a negative influence on affective state, and the circadian dys-synchronicity that results from shift work, common in equine veterinary medicine, can predispose to depressive-like symptoms. These various influences are collectively referred to as affective dispositions to respond (ADRs) and compromise cognitive control and therefore the efficacy of clinical decision making (Table 1): 

Table 1: Potential Chronobiological Influences on Affective Dispositions to Respond

 1. Specific affective biases in decision making 

2. Endogenous affective disorders within the clinician 
•  Depressive disorders 
•  Anxiety disorders 
•  Manic disorders 

3. Emotional dysregulation in clinicians 
•  Unconscious defences, avoidance, anxiety 
•  Emotional involvement or detachment 

Adapted from Henriksen et al (2005). Advances in Patient Safety: From Research to Implementation. 

Long hours of work, sleep deprivation, stress and accumulated sleep debt are common in the equine veterinary workplace. Generally, the longer people stay awake, the sleepier they become and their cognitive and psychomotor performance is impaired reaching its nadir between 3-4 am when cognitive performance is the equivalent of being intoxicated. This brings in to sharp focus veterinary actions to perform intricate surgery, or make life-influencing decisions, during those hours or, perhaps suggesting that postponement to daylight hours is preferential.  

There has long been an association between sleep deprivation and medical error, and was found to have the greatest impact on diagnostic error with interns making substantially more serious errors when they worked frequent shifts of 24 hours or more than when working shorter shifts. This was supported in later studies which also identified additional effects including a higher predisposition to road traffic accidents, a highly relevant finding for the ambulatory vet. 

Interestingly people are recognized as demonstrating different chronotypes, with their sleep-wake cycle to the light-dark cycle differing between individuals. This is generally expressed as “larks” for early chronotypes and as “owls” for late ones and can be quantified perhaps suggesting the possibility of selecting people more suited to certain shifted roles. 

Whilst a number of chemical aids have been used to alleviate fatigue and psychophysiological performance their effects were limited and more work needs to be directed at management with preventative strategies and protocols implemented to reduce the potential for diagnostic error addressing both CDRs and ADRs.  These may include heightened metacognition, simulation training and development of cognitive forcing strategies but could just as well be asking for a few more hours in bed. 

 Ben Sturgeon




Wednesday, 8 March 2017

How do you know you exist?

The short answer is you don’t. But is very clear that each of us tends to have a robust experience and sense that “I exist.” In the latest Veterinary Record (180(7):165) a study is presented examining the potential benefits of exercise in stress relief. You can almost certainly predict the results and whilst I in no way belittle a novel approach, I believe it goes far deeper than a simple biological saturation with endorphins.

I was asked, in an interview, several years ago, why did I think vets, including myself, undertook extreme sports during their down time? I answered it was because of their type A personality but knew that answered nothing other than incorrectly associating cause and causality.

Interestingly there is a neuropsychological condition called Cotard’s syndrome, where people are convinced they do not exist. It has been shown that in such people, brain scans demonstrate that activity in the area of the brain associated with internal awareness is low. Down even to levels seen in people who are minimally conscious and so creating a perception of non-existence.

In the deeply claustrophobic world of depression, a plight suffered by many and seemingly increasing numbers of vets, there is often a feeling of non-existence. A living state of existence without value, existence without recognition, existence without self.

I know that going for a run, no matter how endorphin inducing, does little to remove this core feeling, and it is in my view crass to suggest to a sufferer to “go for a run.” Extrapolating from Cotard’s however suggests that by creating a vivid perception of our body and its various states, our brain also generates the feeling of existence of self, a vital sense of worth that may aid in a simple but vital step toward improvement.

But is not just perception of our bodies, it could be perception of spaces, of environments, of countryside, of people, music, art, food, science, dance….. Anything that reawakens the mind and person to their existence as a vital and necessary human being. Whilst the need for recreation and escapism will always exist, whilst exercise is a valid aspect of therapy, don’t forget or ignore that the variety of life may be all you need to remember and remind you that you do truly exist.

Ben Sturgeon

Thursday, 23 February 2017

The problem with Women…

I think I’ve finally figured it out. Why women are always late. Or at least why I’m almost always late or rushing not to be late. It all comes down to the difference between men and women, and how their brains are wired up. This startling revelation (to me at least) has taken me two children, three dogs, one husband and at least twenty years of multi-tasking (albeit badly) to work out.

Take for example one of my super busy, successful parent friends from school. We were all rushing around last week trying to shepherd unruly 5 year olds into their swim class (which involves somehow getting the most awkward plastic bright green swim hats onto them without causing tears) when she realised she didn’t have to rush off as usual to pick one of her three boys up as her husband was (unexpectedly) home early.  She paused for all of 60 seconds before rapidly re-calculating what she could do with the unforeseen “spare” 20 minutes in her day. She worked out that she could either fill the car with fuel or pop into the supermarket on her way home, thus saving a job for the following day and freeing up more time…to fill again. Maybe we need to learn to use “spare” time to catch a breath instead?

Another friend (male this time and a successful business man) agrees that we approach things differently. He is forever telling me to “cut the waffle” – apparently I could say everything I need to in an email in half of the words. So what I perceive as a blunt or impersonal message seems to be viewed as assertive and to the point by the men who receive it. I will admit that this has made me re-think how I approach my emails. Don’t get me wrong, I still write long, chatty messages to my girl friends but my BEVA emails are thankfully getting shorter and more succinct. And I’m trying not to read into the tone of text and emails…it is so much better to pick up the phone than second guess a written (often in haste) message.

The same friend also pointed out another reason for my ever-increasing workload. I’m too impatient. If his wife asks him to do a job, she expects it done in five minutes. If he procrastinates, she gets on and does it herself. How many times have we muttered to ourselves “I would be quicker doing it myself” and then borne a slow burning grudge of resentment? Men are the cleverer (or lazier?) species here…they have worked out if they take 15 minutes to procrastinate then their female partners will probably do it for them by minute 10. I guess this is a little like chess…and I need to learn to delegate and be more patient.

And finally I’m easily distracted. Performance coach Andy McCann presented a really thought-provoking plenary lecture at the VMPA/SPVS congress recently. According to a University of Pennsylvania study, male and female brains are wired differently: male brains are wired front to back with few connections bridging the two hemispheres. Women’s have pathways criss-crossed between left and right. So whilst men are better at learning and performing a single task, women are equipped for multi-tasking. But I’m sure it’s only multi-tasking when you are actually performing each task efficiently. I may think I’m multi-tasking listening to a podcast whilst typing an email and eating lunch but I’m sure I’m not doing any efficiently. Perhaps I need to think more like a man and focus on one job at a time. And then I might actually listen to what my husband and dad say?!

I came across this lovely story when researching time management and effective multi-tasking

“Rocks, Pebbles and Sand – The important things in life”…

A philosophy professor stood before his class with some items on the table in front of him. When the class began, wordlessly he picked up a very large and empty mayonnaise jar and proceeded to fill it with rocks, about 2 inches in diameter.

He then asked the students if the jar was full. They agreed that it was.

So the professor then picked up a box of pebbles and poured them into the jar. He shook the jar lightly. The pebbles, of course, rolled into the open areas between the rocks.

He then asked the students again if the jar was full. They agreed it was.

The professor picked up a box of sand and poured it into the jar. Of course, the sand filled up everything else.

He then asked once more if the jar was full. The students responded with a unanimous “Yes.”

“Now,” said the professor, “I want you to recognize that this jar represents your life. The rocks are the important things – your family, your partner, your health, and your children – things that if everything else was lost and only they remained, your life would still be full.

The pebbles are the other things that matter – like your job, your house, your car.
The sand is everything else. The small stuff.”

“If you put the sand into the jar first,” he continued “there is no room for the pebbles or the rocks. The same goes for your life.

So if we multi-task and fill every minute trying to get “stuff done” we may miss the important things in life. As my Dad keeps reminding me “Never get so busy making a living that you forget to make a life”….or the rather priceless “you must find time to sit on you’re a*^e and contemplate”.

Vicki Nicholls


Monday, 6 February 2017

Booze

I’ll let you decide and by the end perhaps we’ll disagree?  I’m not an alcoholic, maybe that’s the first sign I am.  I’m not because I know full well the how and the why it happened and I know what to do to stop. 

There are many vets who accept that complaints, legal accusations and professional questions are just part of the job.  They accept it as part of the 9 to 5 and move on.  I’m not one of them. I wish I was, but each questioning accusation or each occasional loss of a client I take personally.  So much so I question every action I made in the lead up to that moment.  An introspection, a self-examination, a dissection of my personality.  It always results in the same conclusion, “I could have done better.”  But you know what?  It actually doesn’t end there.  “I could have done better, I could have been more thorough, I could have been more professional, I could have been a better person.”  It is this spiralthe snakes and ladders lifestyle of an equine vet that gives us a profession of ozone rich high and calamitous methane lows.   

We are trained to review and evaluate, it is a clinical skill, but it often leaves us feeling that we don’t know enough, didn’t do enough, or now and most fundamentally, do not matter enough. 

The spiral can continue, “is my professionalism sufficient, am I one of the misguided who should leave the profession to ultimately respect primum non noncore, is it right I leave my family in a potentially parlous situation based upon my wit or lack of, to survive in this velvet glove world of cloak and dagger?” 

Booze usually starts as a quiet tipple.  The end of the night wind down.  But for me, when staring into the abyss that is my inner reflection, conscience and consideration of my soul and core, booze becomes a way of shutting out that clarion call of a brain screaming at you – “you’re not bloody good enough!” 

I first recognised this at university.  4th year and exams at the end of every subject or every 4-6 weeks.  Each and every one counted towards finals and the questions we sat in the exam were the very same we had been taught only the previous day.  This may be the norm now but at the time we were the first year to try this, the guinea pigs and no one knew how it would go.  At the end of the first term one friend was in hospital due to stress, another on anti-depressants.  I and most other students hit the bars.   

Second term was more of the same only this time the end of night collapse into bed and finding of anxious sleep was eased by Vodka.  A bottle or two a week, a method of escape by any means.  Luckily within a couple of months I realised the unhealthy spiral and made the active decision not to loose sleep over exams, not to base my health on success or failure.  I decided that if I failed, I failed,  so be it.  Better that attitude than succumb to further booze or follow my colleague into hospital.  Luckily, thankfully or perhaps deservedly I passed and my attitude continued to final year exams with the same results.  In fact excelling and achieving University recognition. 

Time passes and we each gain experience and responsibility.  Sometimes both are thrust upon us without a desire to receive but it is part of “the job.”  Booze hit me again 10 years later due to an RCVS investigation.  Forgive me for not supplying details suffice to say I was not fraudulent, not lying, not unethical, merely na├»ve.  It was ultimately thrown out but the process led to the soul searching each of us does in that situation. 
I remember the letter and I physically shook for 5 days.  Whilst the physical manifestation went, the emotional burden that availed me lasts to this day and during the 18 months it took to resolve I regularly found solace in the bottle.  Whiskey this time.  At it’s worst, half a bottle a night. 

I wasn’t an alcoholic, I didn’t wait for opening time or dive into it the moment I went home but used it only to bestill a mind that shouted even though my personality became mute. 

I was lost in a morass of mental doubt at this point and couldn’t see the dangers.  Out of hours were worst because of the quiet when all you have for company is your mind. 

Ultimately and with a slow return to self I recognised the behaviour.  Perhaps this is the moral or the kicker or where we’ll agree to disagree but I didn’t and still do not consider the behaviour wrong, I needed something to alleviate the mental pain and it did.  This is not wrong but a normal human behaviour to seek respite from a stressor.  Some may drink, some take drugs, some seek physical contact, some self flagellate through physical pain.  All are simply human reactions.   

What, of course, we should do is seek help in a non-damaging way.  Through spouse or partner support, through counselling, through friends and professional aid.  But at that point, when your brain is ablaze and your inner voice is in conflict, you don’t think straight, you don’t rationalise, you look for respite, I reached for the bottle. 

Ultimately I sought counselling to allow me to understand and hence control my emotions and actions.  Even when the case was dismissed I continued to question even more if I wanted to remain as a vet in a profession which would or could expose me to such torment apparently without empathy or personal consideration. 
That is why I carry it today, waiting perhaps for the next circumstance or shift in luck for the pendulum and sword of Damocles to sway back again.  I hope this time I’ll be better equipped to avoid the pitfalls.  Perhaps I will, perhaps I won’t.  Sadly I know I won’t, it is partly my nature, but I will know it is damaging and the phase will be short. 

There by the Grace of God go I and we should all be mindful of the situation of others, do out best to recognise, and do our best to empathise.  Sympathy, understanding and support is all anyone would ask for and it is in the power of all of us to provide it. 


If you have been affected by this story or want to talk confidentially about this or a similar subject then contact Vetlife here https://www.vetlife.org.uk/