Background: About This PBL Case
This PBL case is focused on the impacts of acute stress, breaking bad news, and long term impacts of these experiences on health professionals. The case was written with input from the fields of paramedicine, clinical nursing, psychiatry, and veterinary medicine and is intended to be applicable to all health professions that are required to break bad news. The intended student level for this case is the undergraduate level for any health profession, however it can also be utilized for post-graduate and continuing education. The case has been designed to include minimal medical information to avoid distracting learners from the intended focus. Tutor probes are included to help facilitators guide the discussion when needed.
Day 1: Managing Acute Stress
Alex is a recently graduated primary care paramedic who has been working for a rural paramedic service for the past month. Today she and her partner, who has five years of experience, are responding to a report of a motor vehicle collision (MVC). This dispatch information indicates that the call is for a two-vehicle motor vehicle collision at the intersection of a highway and a grid road. On their arrival Alex and her partner note that a dump truck has collided with a half-ton pick-up truck at the intersection. The driver of the dump truck approaches them as they walk toward the scene and he appears uninjured.
As Alex approaches the pick-up truck, she notes extensive damage to the front driver side of the vehicle. There are two adults in the front of the pick-up truck and Alex notices that the passenger is alert and holding a chihuahua who is vocalizing loudly and appears in distress. Alex approaches the driver who appears unresponsive, has fast shallow respirations, and blood on her face.
Alex is preparing to assess the driver, but she can feel her heart racing in her chest, and she is finding it hard to focus on her priorities. The scene is loud and chaotic. Several bystanders have begun to gather around the vehicle. The fire department and RCMP have also arrived on the scene.
- What is acute stress?
- How does our physiology change when we are exposed to acute stress?
- What are some signs and symptoms of acute stress?
- What are some factors or events that can induce stress?
- Can the physiological disruptions of acute stress affect our decision-making abilities?
- Can the physiological disruption of acute stress affect our ability to perform skills like intravenous insertion and intubation?
- Are there techniques that we can use during a stressful event to help manage our physiology?
- Are there techniques that we can use prior to an acutely stressful event or that we can build into medical education programs that will help providers manage acute stress?
- Does our ability to manage acute stress improve as we gain more experience?
- What can be done after experiencing acute stress to minimize the long term impact?
- What impact can acute stress have on our ability to function as healthcare providers?
- What are some steps that can be taken prior to a high acuity event to help health care providers manage the effects of acute stress?
- What techniques can be used during a high acuity event to help alleviate some of the effects of acute stress?
Day 2: Breaking Bad News
The passenger appears stable and tells first responders his name is Steve. He and his partner Julie, the driver, were on their way to a vet appointment for their 18-year-old Chihuahua named Rex. Rex was recently diagnosed with Congestive Heart Failure (CHF) and Steve is worried about Rex’s quality of life. Rex now spends most of the day sleeping and when he is awake, he seems to wander aimlessly until he gets out of breath which causes him to panic. Rex’s panic attacks are upsetting Steve and he is losing sleep and having trouble focusing at work. Steve and Julie have not talked about it directly, but Steve is wondering if it’s time to let Rex go. A bystander offers to drive Rex to his vet so Steve can be taken to the hospital with Julie whose condition has continued to deteriorate. She is now being manually ventilated. When they arrive at the hospital Steve asks why Julie needed to be taken to the hospital so urgently and if she is going to be okay.
- What are the ABCDE and SPIKES models of breaking bad news?
- How can using these models help Alex or the hospital staff discuss Jamie’s condition with Steve?
- How could you adapt these models to your profession?
- How could you adapt these models if you needed to break bad news to a child?
- What resources exist to aid health professionals who are affected by delivering bad news?
- How does Rex’s CHF and “aimless wandering” affect his quality of life?
- What impacts do palliative conditions have on owners, caregivers, and relatives?
- What grief responses can be seen with end-of-life decision making?
- Do grief responses differ when the patient is a pet vs a person?
- How can health professionals facilitate end of life discussions?
- What resources exist to aid pet owners in quality of life and end of life decision making?
- What are the principles of Trauma Informed Care?
- How can the principles of trauma informed care be applied to your health profession?
- How can breaking bad news contribute to burnout and compassion fatigue?
- Can breaking bad news contribute to vicarious trauma?
- As a human health practitioner how would you break bad news to Steve regarding Julie’s grave condition?
- As a veterinary health practitioner how would you discuss Rex’s quality of life and end of life decision making with Steve?
- How can a trauma informed approach help both human and veterinary health practitioners who are interacting with Steve during this stressful situation?
Day 3: Managing Long-Term Impacts
Two months later, Alex, the paramedic at the scene of the motor vehicle accident, continues to experience recurrent nightmares about the incident on a daily basis. She has started to take the long route to work as the most direct route has a car dealership along the way. Her colleagues have told her that she often “spaces out” for 10-20 minutes at a time while at work. Her husband has also shared these observations when Alex is at home as well. Furthermore, her husband has noticed an increase in her irritability and has started to encourage her to “get help.” In light of these observations, Alex has decided that it would be best for her to take disability leave from working as a paramedic. She has a discussion with her boss about her situation who recommends she see her family doctor.
At her appointment, she describes her symptoms to her family doctor and afterwards asks, “What’s wrong with me, doc?”
- What could Alex be experiencing?
- What is PTSD?
- What might be happening when Alex “spaces out?”
- Are there any other questions you would like to ask Alex?
- Which professions are more at risk for developing PTSD? How common is it for first responders to experience symptoms consistent with PTSD?
- What is the difference between an acute stress reaction and PTSD?
- What other mental health conditions are usually associated with PTSD?
- How can families and friends best help individuals with PTSD?
- What interventions can help with treating her symptoms?
- What other psychiatric symptoms should be screened for in Alex’s situation?
- Are there steps Alex’s workplace could take to help protect other employees from developing PTSD in the future?
- What roles does the Canadian OH&S (Occupational Health and Safety) have in this case?
Case Info (Cont’d)
6 months later, Alex continues to regularly go to counselling for cognitive behavioural therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). She reports to her husband and colleagues that her symptoms have significantly improved but she continues to have occasional nightmares. Generally, her mood and irritability have improved. She continues to be on disability leave but plans to return to work with reduced hours. She and her employer have created a Comprehensive Workplace Health and Safety (CWHS) Program and a return-to-work plan with modified responsibilities such as buddy shifts and avoiding tasks that may retrigger her PTSD symptoms.
- According to the DSM-V, what is the diagnostic criteria for Post-traumatic Stress Disorder (PTSD)? Does Alex’s symptoms fit the diagnosis of PTSD?
- What non-pharmacological treatments are recommended for Alex?
- What role does the Canadian Occupational Health and Safety (OH&S) have in supporting workers suffering from PTSD?
- Health care workers are susceptible to experiencing symptoms of PTSD. Reflecting on your past experiences, what has helped with managing burnout and what can you do to prevent trauma from developing into PTSD?