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Key points Beginning to understand the complexity of physical health concerns in people with mental ill-health conditions will help move practice towards a more holistic approach Embracing health promotion can have a positive impact on patients' physical and mental health Looking at ourselves and how we practise can only be of benefit to those we come in contact with CPD reflection questions for paramedics Have you ever witnessed diagnostic overshadowing, and how did it affect the patient? Do the challenges of dealing with mental health patients obscure your own consideration of the physical health aspects when caring for patients with mental illness? Do you consider health promotion with patients, and does this change with those experiencing mental health problems? How can you make changes to your own practice to address the issues raised in this article?

I don’t ‘do’ mental health. Growing up, my family always had a stiff upper lip, told me to "take a breath and get on with it". It was seen very much as a weakness. If I was ever feeling upset about something that had happened at work, they would always retort back with a story far more gruesome and awful than mine. My family are all healthcare professionals. Dinner table talk usually turned to horror stories of car crashes, attempted murders, limbs falling off, wounds and cardiac arrests. Very interesting and often led to great discussions, but didn’t explore how we felt about being involved in the worst days of other peoples' lives. My family spoke of these incidents as if they were viewing through glass, an invisible wall. They distanced themselves. This is how they dealt with the horror of healthcare. From their behaviour and how they dealt with ‘work’, I followed suit. It seemed to work. Something bad would happen – a traumatic cardiac arrest at the roadside, a stabbing of a young man, a four car pile up with three dead at the scene, a murdered child – I would then go back to my family home on days off, have dinner and we would swap stories. We would all try and out do each other, a bit like a game of gruesome top trumps. But I could not brush off what I had seen. I saw the trauma that was inflicted on survivors, the pain people had been through, the raw emotions from other during the worst day of their lives, the conditions people lived in. I was seeing this daily, not once a month or once a year, daily. It was bound to take its toll. All was going well, or so I thought. Until my life got in the way. I have two boys: 13 and 11 years old. Starting out in the world. I have been able to keep them safe; I keep them away from these horrors I see. I have protected them from the society we live in. The knife crime, the drugs, the violence, but as they grow up they have become more independent. They want to go out alone, they mix with other groups of kids I don’t know. No longer can I call the parents of a child I deem ‘suitable’ for a play date. I am relying on my children to make the right choices. I felt out of control. Whereas at work, I am in control. I may not have control about which job I go to, but I have control on how I manage the patient, I have drugs to ease pain and can give immediate treatment. I feel as if I am in a ‘bubble of professionalism’. What happens at work, stays at work (or my parent's dinner table). But here in the real world, there is no bubble. I tried bringing my feelings about the loss of control and fear around bringing up boys in 2020 at the dinner table. "That’s life," announced my dad. "We got through it and you're OK," said mum. And that was that. My feelings were deemed as mundane, not good enough to discuss. Before I knew it, the conversation had moved on to a patient who needed helicoptering off a rugby field with a broken leg. I wasn’t sleeping. I couldn’t concentrate. I had this weird pain in my chest. All I could think of was the safety of my boys. I replayed scenarios of them getting run over, getting into a fight and getting stabbed, being involved in a car crash. I wouldn’t go on unnecessary journeys in case we crashed and they died. I was just about coping with work. I did not have the capacity to take stress from any other angle. So, when I needed to step up to the plate at home, bringing up kids, it was all too much. Getting help I made an appointment with a GP. I’m never ill, so don’t see a regular one. Any GP would do. I wanted some help, but wasn’t sure what help was available. I felt embarrassed about going. I didn’t tell anyone. Once I was in there, I just burst into tears. I’ve seen GPs behind closed doors, people do it all the time. I bet they get sick of it. I was now one ‘of those’ people. She heard my symptoms; she heard the causes. With that she wrote a prescription for Sertraline (a drug for anxiety) and an offer to sign me off sick for 2 weeks and I was out the door with a follow up in 3 weeks. Looks like I am labelled now, and it took less than 10 minutes. Were pills the answer? Surely there are other therapies I could try? I don’t want time off. It won't make it better. After opening up to a colleague at work, it seems myself and my family are suffering with moral injury. The term ‘moral injury’ has been used to describe the psychological effects of ‘bearing witness to the aftermath of violence and human carnage’ (Litz et al., 2009[1]). Carnage sounds like a normal shift to me. The symptoms of moral injury are strongly linked to feelings of guilt and shame and can manifest as social isolation and emotional numbing. This was my mechanism for coping with the stress at work. Numbing the emotions, not allowing my emotions to show themselves in fear that I would not be able to do my job. I’m no good to anyone being a blubbering wreck am I, everyone else is OK, so I must hold it together. Binned the pills I was told about ‘talking therapies’ that my employer can refer me to – for free. I went to my line manager. We spoke at length about how I felt, and she referred me to the talking therapy provided by my Trust. While I waited for the appointment date, I opened up to friends. Found out I am not alone. Seems we are all struggling in different ways. Being able to speak freely with a trained counsellor has really helped. I have strategies to help me with anxiety and stress, I have started the NHS couch to 5K and have started to feel so much better. I have not taken the pills offered by the GP. I’m sure some people need them; I feel I don’t need them at the moment. We know that we need to have more and better conversations about our mental wellbeing, and it is worth thinking about what kinds of conversations might be useful; certainly a game of top trauma trumps isn’t a good idea while eating sausage and mash. It is true what the literature suggests, that paramedics are suffering from increasing rates of post-traumatic stress disorder (PTSD) (Regehr et al., 2002[2]), but it is also true that not all those who are psychologically affected by their work, even in lasting ways, will reach the threshold for a diagnosis of PTSD. Some people will become ill as a result of their work, and some will become distressed; moral injury offers a different way of thinking about the psychological harms that may result from the practice of prehospital and emergency medicine (Murray, 2019[3]). This may give paramedics and other ambulance staff the opportunity to think about the impacts of their work in ways which do not threaten their ability to do it. Ensuring there are opportunities to sit down and talk through their jobs in the course of a working day, or night, could be the best place to start (Murray, 2019[3]). References 1. Litz BT, Stain N, Delaney E et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev 2009;29(8):695–706. 2. Regehr C, Goldberg G, Hughes J. Exposure to human tragedy, empathy and trauma in ambulance paramedics. Am J Orthopsychiatr 2002;72(4):505–13 3. Murray E . Moral injury and paramedic practice. Journal of Paramedic Practice 2019;1(10).

About the author Jo Mildenhall is a Doctoral Research Student at Manchester Metropolitan University; and Paramedic Team Leader, South Central Ambulance Service NHS Trust, Newbury Ambulance Station.

The PRSB have collaborated with the Royal College of Physicians Health Informatics Unit on this project. Clinical leadership was provided by clinicians from the Royal College of Emergency Medicine and the College of Paramedics (CoP). The standard has been developed with the support of professionals and patients. This resource includes: The standard Information model Information model (as Excel spreadsheet) Documentation Ambulance handover standard final report v1.0 Implementation guidance v1.0 Clinical Safety Case Report v0.3 - Currently being approved through the NHS Digital Clinical Safety Group Hazard log v0.7