'Emotional Control' Key to Knife Crime Life-saving Trauma Surgery

Edna Astbury-Ward

September 24, 2019

Birmingham – Treating victims of knife crime is a growing part of emergency surgery in the NHS but how do surgeons manage such complex cases?

The Royal College of Surgeons held a special event focusing on knife crime. Medscape UK has already heard from Mr Ewen Griffiths about the "public health emergency" of knife crime. Now Ms Nabeela Malik, trauma research fellow and ST6 general surgeon at the Queen Elizabeth Hospital, Birmingham shares her experiences.


Ms Nabeela Malik

Ms Malik also serves as a major in the Army Medical Services 212 Yorkshire Field Hospital.

Calmness, emotional control, compassion and a very thick skin are just some of the essential characteristics required for surgeons who treat trauma and knife crime victims says Ms Malik, who has an MSc in trauma science. She presented her research to delegates at a multi-professional conference on knife crime in the West Midlands, and she talked to us about her work.



How do you keep a cool head in an emergency knife trauma situation?

I think you've got to learn emotional control at a very early stage in surgical training and by the time you are at the stage where you are a decision maker in that situation you’ve done it a few times. You've got to just keep in mind what the priorities are in terms of what you need to do to keep a patient alive.

It must be very fast paced?

Yes, and you've also got to deal with everybody around you because there are often lots of doctors at once at a trauma call, everybody will have adrenaline going. You train yourself over a number of years to be calm under pressure and that's one of the defining qualities of a surgeon. People who go for a career in surgery will have to be able to exercise emotional control, and be able to focus their thoughts in a high-pressure situation.

Do you think that's a skill that comes easily to surgeons or do they have to work on the emotional control?

I think within surgery there's as many different personalities as there are in the general population, everybody will have different things that challenge them, whether it's emotional control, or technical skills or being able to get along with other colleagues, every surgeon has different challenges.

We heard from all the speakers today about the rise in knife crime, does it make you despondent?

I think it's very sad that young people in our cities are falling victim to knife crime. I think what's sad, as I've found with some of my research, is that some people are coming back again and again with violence related injuries, the rate of violence recidivism is higher than we thought and that's very sad. Birmingham is a city that I've lived in and grown to love and knife crime is certainly a problem here. I have struggled with the fact that so many young people are losing function or losing their lives as a result of knife crime but I am also pleased that I have the opportunity to do work to try to counter this problem.

Do you think the media plays a part in this?

We highlighted in our talks that people like President Trump have got an impression from the media that everybody's carrying a knife and that there is blood on our hospital floors. I don't think the problem is that severe, it has risen, but in general, most of our cities are law abiding and this is a lovely place to live. I feel very sorry for those who do fall victim.  I do think that if you only listen to what the media say, people think that the problem is much worse, describing our cities as a war zone seems to me not very accurate.  Some youth charities feel that the media has perpetuated an impression that all young people are carrying knives and this makes some young people feel like they have to do the same too.  It is hard to say this for sure but many people feel this way.   

Do you think we need to do more at the place of attack, rather than wait until the victim is taken to hospital?

I think what we need, is to do more to prevent the attack from happening in the first place.

We've talked about all of the social risk factors, adverse childhood events, cuts to the police force, austerity, all of those things, so multiple factors can make a person prone to suffering violence or perpetrating violence.

Do you think doctors have a role in the external social factors?

I think as surgeons and doctors in the hospital we can do more in terms of engaging with the other agencies such as the police force, Public Health England, injury prevention charities, to reassure the public that we're here for them. We can share our learning and data and findings from hospitals to inform the practice of the other agencies to help to reduce knife crime. It's a huge multi-agency, multi-disciplinary, multi-professional requirement, needing a massive amount of resources.

Tell me about your humanitarian work and what skills you bring from there to the NHS

I think one of the key skills is that sometimes you've got to do things and you don't have the ideal kit or people to help, so you have to be adaptable. That's probably one of the biggest transferrable skills. But also, learning to deal with the feeling of being completely overwhelmed at times is important. In some humanitarian situations, there will only be a handful of doctors and hundreds of patients waiting to be seen. You have got to just try to do the best and accept that you're in a bad situation, you can only try to make it better. Also, learning about yourself and how you respond to situations is important. I think a high level of self-awareness and reflective practice can make you a more effective clinician in the NHS and working in austere settings encourages this.

What would you say is your greatest achievement or success in the surgical field related to knife crime today?

I think one of the biggest achievements so far, has been conducting studies, which has revealed things that many of us didn't know, so presenting my work today was quite a highlight for me.

What did you find most surprising in your research?

All of the previous studies have been published by Londoners about London, yet the Midlands and the North have seen a massive increase in knife crime, and we don't know how generalisable the findings of the London studies are to centres outside of London. So cities in the Midlands and the North have a similar profile, in that they are large, post-industrial cities that are having to reinvent themselves. They have a younger population, so we have more in common with each other in terms of cities in the Midlands and the North than we do with London. Being able to present my data today and discuss the findings has demonstrated that knife crime is not just a London problem, it is everybody's problem. Our patient group might be slightly different from theirs and our systems of care certainly differ from theirs, but our system in Birmingham appears to be equally effective in terms of our mortality data, that is, how many patients we are able to save. So that's a proud moment for me.

As the surgeon who deals with victims of crime, what would your message be to other surgeons who were thinking of becoming involved?

I would say, the basic principles of saving life and preserving function apply but we've illustrated very well through all the presentations today, that it's a team effort and working as part of a team with other specialties and other personalities in a high-pressured environment is required in order to achieve the best outcomes for our patients. I would also encourage surgeons at other centres to look at their data and share this with their colleagues and organisations within their cities to try to work together to tackle knife crime.

How do you react when saving the life of a person you know has harmed or killed another person?

I would say that it's not for us to judge. It would be an oversimplification to say that we are technicians, we do a lot of decision making but the actual nature of the illness, whether someone has tried to kill themselves or has acquired a very rare cancer through no fault of their own, should be treated in the same compassionate manner. This is one of the fundamental elements of the Hippocratic Oath and the whole ethos of our profession, not to judge why somebody is ill, but to do what we can to make them better.

But you must have some emotions relating to this?

I would say it's very sad that lots of knife crime patients are young and able men who we shouldn't be seeing in hospital, they should be active and healthy, so it's very sad to see them come in, in what appears to be needless violence that has a lasting impact on their lives, physically, mentally and emotionally. But the sense of accomplishment is very similar, regardless of who we are treating, and we will do our best for everybody. One of the things I worry about, which we do not really get involved in as surgeons, is that many of these young men will suffer psychologically after being stabbed and it would be interesting to know whether they are able to return to normal living and work afterwards. I am sure that their parents, siblings and partners are affected too.

Is there sufficient support for surgeons to be able to cope emotionally with those feelings?

I would say that as a surgeon, you have to be resilient, you’ve got to be very thick skinned. Knife crime patients are not that different from young people who come in with cancer who have lived a healthy life, or children who have sustained injuries. So, a lot of our patient groups do provoke an emotional response in us. I would say there isn’t formal provision in terms of a counselling service by the Hospital or the College for support in that regard. I would say that we all have our own support mechanisms, having a healthy family life, a good social life outside of work helps, and very importantly, having colleagues who you can go and talk to, who understand the situation you are in. I think support from colleagues is really important, being able to share the burden of what you’ve been through and maybe reflect on some of your decision making and technical skills about whether what you did was right. Colleagues are a big source of support and working within a supportive team is very important when you are dealing with emotionally charged cases. It is also very important for our teams to get together and debrief over a cup of tea about the patients who die and give team members the opportunity to share their emotions and reflections before moving on from the death of a young patient.


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