The terrible news of the attack on the Manchester arena was both shocking and familiar. How could someone attack children and young people, the most precious in our community?
As I listened to the unfolding story I could not help my thoughts returning to the events at Dunblane. They are so different, but in both cases the most vulnerable were targeted, the attacker was dead, and so many questions can never be fully answered. We initially thought that the small town of Dunblane would never recover – how wrong we were. I am sure that the people of Manchester will, like the people of Dunblane, show the bravery and resilience to hold their communities together. Both will continue to receive our love and support, although life will never be the same again.
There is however, in the background, another special group, the emergency responders, on whom we rely for Dunblane, Manchester and every day. Do we provide as much support or help as they deserve?
Shortly after the Dunblane shootings, I wrote a small opinion piece for the British Medical Journal called 'Annie's Place'. It recounted a meeting of emergency doctors I chaired three days after the tragedy. Between them they regularly saw more traumatic deaths every week than Dunblane. Each had developed their own ways of dealing with the continuing stress of the job. Many had found a special place where they could go between work and home to allow them to reduce the stress before returning to family life.
I had mine. I called it 'Annie's Place' after the landlady of the pub near the lifeboat shed in the village where I was a local GP and crew member. When you became involved with the lifeboat you were given an invisible membership card to the club. Its unspoken rules entitled you to express your thoughts, successes and anger easily and in safe surroundings; in return you had only to agree to listen to the others.
What made Annie's Place special was that, whenever the lifeboat returned from a 'shout', no matter what the time of day or night, there was always an open door, comfort and reassurance. The same ritual was followed wherever possible. The boat was rehoused, refuelled, and washed down ready for service. Equipment was checked and the families told that we were back safely. After that we went to Annie's. Some people stayed and talked, others sat quietly in the corner. If someone had been less than perfect in their actions it was discussed, but never in a destructive or aggressive way. Sometimes we drank tea and ate toasted sandwiches.
Occasionally a bottle of spirit was ceremoniously downed. If Annie's had not been there each one of us would have returned home with our thoughts still occupying us. When we answered the call, we had left unsettled the usual minor domestic crises. I often had to abandon family or patients without much warning. Those left behind had to keep the home or the practice ticking over, and yet they also realised that sometimes lifeboat crews do not return. In these circumstances the normal expressions of relief could have caused additional unwanted stress. Annie's provided the buffer for us and our families.
Responders and the other 'blue light' colleagues in the police, fire, and ambulance services, and the many volunteers in the RNLI, coastguard, and mountain and cave rescue teams between them attend hundreds of victims every day. The major incidents hit the headlines but the stream of unnoticed 'normal' trauma is overwhelming. While you read this, they are working to keep you and those you love safe. They often work in situations which can be life-changing or life-threatening to victims and themselves.
Protocol informs their actions, but each patient is an individual and may be aggressive, mentally unwell, affected by drink or drugs, or be the victim of violence. Patients also have friends and family, and dealing with these adds an extra degree of complexity. Into this cauldron of uncertainty arrives the responder, trying to bring calm professionalism to a fragile scene. It is easy to feel inadequate or make decisions which, in retrospect, were not optimal. The universality of mobile phones and the rapid communication by new media place each incident under an increasing level of scrutiny.
There have been some massive improvements. Training is more comprehensive and evidence-based. Equipment is unrecognisable from the minimal range previously available. Communication from the scene, and rapid transport to specialist trauma centres, have led to significant improvements in morbidity and mortality.
Against these benefits there have been some major constraints. Financial limitations require providers to improve efficiency with creative ways of getting more out of personnel and equipment. Increase in demand and falling funds mean ever-increasing pressure. Response times are reduced by using volunteers or professional first responders attending alone. The volunteers fill the gap until professionals arrive, but feedback can be haphazard. The professional is directed by their control from incident to incident. They make quick assessments, but often get called away as no other resource is available.
From speaking to working colleagues, they only see a steady deterioration in their workload, increase in stress levels, and little chance of escape as the retirement age seems to always be a little further over the horizon. Those who are staff turn up to their shift, start work by facing a backlog of problems, must multi-task because of the pressures, miss meals and finish exhausted well after their shift ends. They have the stress of violent patients, concerned families, pressurised management, and a seemingly endless flow of patients. When the shift eventually ends, there is no time to de-stress with the commute home and the return to the everyday problems of family life. These organisational stresses add to the occupational stress of doing the job, and it is not surprising that mental and physical health deteriorates, and it becomes more difficult to recruit and retain staff.
Now, more than 20 years on, it is time to consider what progress has been made in protecting the frontline staff. Poor mental health is not only detrimental to the individual, but also their patients. Indicators of problems such as health absences, burnout and staff turnover have continued to deteriorate. There have been some improvements in formal psychological support, but often people are reluctant to self-refer. Annie's Place allows colleagues to identify problems early and encourage formal support. This early mental health first aid is a proven way of preventing long-term issues such as post-traumatic stress with its disruption for the individual and their family.
We rightly show our concern for those who have served in our armed services and fall on difficult times. They have priority access to specialist support services, a formal financial support framework for them and their families, and a range of active, well-supported charities. Perhaps now is the right time to ensure that we respect our emergency services by providing a similar level of support on a national basis. We should also encourage them to have access to their own Annie's Place to provide self-support and first aid, and identify any need for specialist intervention.
I know that the readers have one outstanding question. How is the original Annie's Place now? Unfortunately, it has closed and become part of the local museum. Let us not commit our emergency staff to the same fate.