Danger, Breakdown Ahead!

This is the final post of three I’ve been writing about my breakdown at work. The other two, When the Plates Came Crashing Down and The Joy of a Broken Toy, covered how my breakdown felt and the process of getting back to work but this blog will cover how I felt leading up to those events. A lot of what you are about to read is pretty unpleasant, far from inspiring and at times quite shameful, I will not attempt to justify any of it, but please hang in there until the end. What I am hoping is that you don’t relate to any of this and that you and your colleagues are nothing like the person I describe below: sadly I suspect this will not be the case for many. If you do recognise yourself in my story, I hope you realise that you need help. The reality is you probably already know but maybe reading this will give you permission to ask for that help. Alternatively, if you recognise a colleague in the behaviours below, if you can see the trajectory they are on, I hope that this might be the trigger to encourage you to do something about it, a gentle push if you will, to reach out and help before they finally breakdown.

Danger, Breakdown Ahead!

I was appointed as the third consultant in an Emergency Department in 1993. I was the fresh young thing, involved in all aspects of the department and also across the wider Trust. Whilst not perfect (obviously) according to my multi source feedback I was pretty much liked by the staff and was considered a good guy to have around but by summer 2015 I was harsh, withdrawn, a bad influence in my department and ultimately weeks away from a career threatening breakdown. It hadn’t happened overnight but was a slow descent into the dark. Sure, there were fluctuations along the way, good weeks, months even and I remained remarkably functional until the end but there were always signs that I was far from well. I’m going to leave the details about why I was stressed to one side, if you work in Emergency Medicine you‘ll know most of them already, instead I’ll just tell you how I felt.

I think the easiest place to start is with the physical impact. I began sleeping badly, struggling to wind down after a late shift, suffering with restless, stress-filled dreams and then waking early to find thoughts of work immediately rushing in to start the day. Obviously that meant I was tired a lot of the time which made concentrating at work difficult and time off hard to enjoy. Not a coffee drinker I started to rely upon energy drinks to kick start my day or keep me going as the afternoon wore on. My skin started to show problems too, I’ve suffered with mild eczema since I was a child and whilst I hadn’t had any sign of it for years, slowly this started to flare up again, become symptomatic and require treatment. The same was true with nose bleeds, an almost forgotten childhood problem which suddenly reappeared during this time resulting in quick dashes to find tissues or the acceptance of blood stains on the front of my shirts. My appetite never dulled but I noticed that my attitude towards food changed.  I would swing between trying to eat healthily, then deliberately chase after fast food… joking that it was a form of self harm yet inside wondering whether there was some truth in that. I think, as I found myself with less and less control over what was happening at work, I tried to regain control in other areas and my diet was one of these. This desire spilled over in to fitness as I started doing extreme exercise plans in an attempt to have control over my body too, to try and control how I looked even if I couldn’t control how I felt.

As time wore on, the prolonged stress started to have other, more worrying effects on me. I began to dread going to work, worrying what I would have to face next, petrified at the thought of another gap in the rota, a bed blocked shop floor or another meeting or email about the four hour standard. It started out with just a heavy feeling in the pit of my stomach each morning but over time it got to the stage where I would have to wait in the car park trembling whilst I talked myself out of the car. Once in work, the anxiety would reappear at times and so I’d make my way to the toilets, sit down and have a quiet moment to myself. I knew this wasn’t normal but I just thought it was something I had to do until I pulled myself together. There was no robustness to my mood, it was egg shell thin. I’d try and start the day with a positive frame of mind but all it took was a fairly minor negative event and I’d be down for hours.

This constant cycle of drawing upon my dwindling reserves of positivity only to be knocked back was emotionally exhausting and it started to show. In meetings I became less constructive, more unpredictable and prone to outbursts. My language changed as I got worse, it became less measured and more confrontational, existing at the extremes of opinion rather than displaying any feeling of uncertainty or nuance, that took too much effort. Words like ‘everyone’, ‘nobody’, ‘always’ and ‘never’ became the norm, there was no balance, no subtly anymore in what I said or how I said it, I’d happily argue ad hominem rather than bother with a coherent rebuttal, it took less energy. Oddly I had a fear of conflict that made me anxious about going to meetings yet was precisely the person most likely to start a fight. My sense of frustration grew as I became incapable of expressing my opinion yet I had to sit there and watch as decisions were taken around me. As time progressed and I had nothing left to give, I slowly disengaged from the agenda, saying less and less until finally I just stopped going to meetings. It was a relief in a way because the effort involved in talking myself in to attending, keeping calm and not just walking out at the first sign of conflict had finally become too much.

At one point I decided I had to leave and applied for a consultant job elsewhere… I didn’t get it. Strangely I wasn’t upset about that, in the end I didn’t want to go, but instead I had been dealt another blow. Writing a CV after almost ten years had forced me to evaluate myself critically, evaluate how I had grown and developed as a clinician and the answer was unpalatable… not much. I’d given most of those years over to chasing the four hour target, working hard, staying late, filling missing shifts and I’d got very good at that. Unfortunately it was at the expense of opportunities to develop professionally because I had fallen into the trap of deeming them ‘inefficient’ and so I had no newer, now core, skills with sedation, airway management or ultrasound. What had this place done to me? I was angry and bitter about what I had lost, what I had missed out on but most of all I was angry because I knew nobody else would touch me now: I was trapped here.

I became more and more self obsessed, concerned only about how events and decisions would impact upon me: survival mode. Selfish, bitter, judgmental and very, very angry about almost everything and towards almost everyone. The junior who phoned in sick, the nurse behind with treatments, the specialty junior unsure what to do next, all of them making my life more difficult, all of them making me angry. Why were they doing this to me? Why were they not up to my standards? Why couldn’t I work with people who were vaguely competent? At its peak I was even getting angry with ambulance crews for bringing in patients! You cannot function with this turmoil going on in your head. To begin with it just eats you up inside, devouring any sense of empathy or compassion, but inevitably the anger breaks through and manifests with an eye roll here or a sarcastic comment there. Eventually the comments which are half in jest become more barbed, the tone of voice changes and you start to draw blood, or at least tears, with your tongue. You become that doctor you swore you never would be whilst at the same time justifying your behaviour because of what is happening to you, because really this is their fault, if they were better at their jobs you wouldn’t have to tell them off… they are getting what they deserve! As you stalk around the shop floor, staff move out of your way, avoid your stare and look for advice elsewhere because now they are afraid of you… but actually that isn’t so bad, at least now they leave you alone.

For me, during these years, this was the thing that hurt most, coming to terms with the reality that this was who I now was. I watched my multi source feedback deteriorate until I could deny it no longer, recognising the person my colleagues were describing, knowing the comments they made were absolutely true and yet knowing that deep down that wasn’t really me. The twin horrors of knowing what you have lost and seeing what you have become, together with a feeling of helplessness to change, is almost literally soul destroying.

But it gets worse, this doesn’t just happen at work, if only it were that simple. The same harsh, angry man comes home in the evening and becomes a harsh, angry husband and a harsh, angry father. It is one of medicine’s cruelest twists that in seeking to maintain a professional attitude at work, we can become too tired to do so at home with those we care about most. I have thought long and hard about what to write next, started sentence, after sentence, after sentence but never really managed to explain adequately my feelings about my failings at home during those years. I will just have to say that I am blessed with a wife and two children who love me, who were prepared to see beyond who I had become and who also understand we all have a need for forgiveness: for that I am extremely grateful.

In June 2015 I wrote in my appraisal folder, ‘My single biggest challenge/achievement is that of keeping going in to work. I can’t see me continuing to cope with it for much longer.’  Reading that back a year later I felt sick. Hopeless and helpless, that’s where I had ended up and eight weeks later I broke. I suspect some of you reading this will be appalled that I could let myself get like this without seeking help, or maybe that my colleagues could let me get like this without offering support but if you work in Emergency Medicine, particularly a busy, understaffed, overworked department, I think you’ll probably understand. Many of us have similar feelings a lot of the time, we just get used to thinking it is normal, not right, just normal. As things get worse you just assume this is how it has to be. I did actually ask for help during that summer but being told I was catastrophising and should try mindfulness wasn’t what I needed at that point. As for colleagues, even if they wanted to help, they probably wouldn’t have known where to start, assuming they had the energy to try. We’d passed around a stress questionnaire that summer and we’d all scored in the danger zone so I don’t hold them responsible, their actions after the event have been faultless, despite their own stresses.

So, that is my story.  If it appears at any point I’ve tried to avoid responsibility for my actions or somehow ‘glorify’ my behaviour, that’s a mistake in my writing. I’ve had to apologise a lot for my behaviour over the years and the fact that I still have a job is down to the understanding nature of my work colleagues. It is amazing what we put up with from each other, what we tolerate because we understand the pressures being applied to us. I’ve tried to thank those who helped in specific ways and apologise to those I specifically hurt but if you are reading this, know me and put up with me in the last ten years then this is for you…thank you and sorry.

Simon

It has been a strange experience trying to write this piece over the last month. My sleep has once again become disturbed, my eczema is playing up and some of the anxiety symptoms have returned. Work is fine and home is fine so I suppose it must be thinking about this that has brought back those symptoms: I didn’t expect that. I’m hopeful they’ll pass now I’ve got this published but it is a timely reminder to me of my need to be self aware and of how deeply rooted these psychological problems can be.