Chair's Corner: Supporting the Second Victim
Have you ever found yourself standing on a highway overpass, watching cars speed by underneath? More importantly, has this ever happened to you at two o’clock in the morning and you wonder how on earth you got to that spot? Well, this did happen to me many years ago -more than two decades, in fact – but I still remember that night vividly.
I had received my MD just over two months previously and had been on-call the night before at the Queen Elizabeth Hospital in Montréal. Part of our responsibility during internal medicine service was to cover the inpatient floors for any medicine problems. I had been called to see a 50-year-old male who was admitted during the day for some nonspecific abdominal pain. He was now presenting with vague back pain and nausea. It was about three o’clock in the morning when I was called to see him and after taking a brief history from him, reviewing the chart and doing a physical exam, I wasn’t much further ahead. However, remembering that certain types of cardiac pain could present with nausea and atypical pain, I ordered some blood work and asked for the ECG machine to be brought up from the medicine floor below (in those days the rotating interns drew the blood in the middle of the night and did the ECGs). I drew the blood and then went down to the ICU to see a patient who I suspected was more ill than the man upstairs. Not five minutes after arriving in the ICU, the overhead pager announced a code blue.
I knew instantly it was my patient. We weren’t able to resuscitate him. I had been talking to him five minutes previously, and had no idea that he was about to die. How could I have missed it? What if I’d done the ECG right away instead of going to see (what turned out to be) a stable patient? What if I’d done a better history? I took the responsibility to call his wife and tell her the tragic news. I also met with the family the next morning, along with the staff physician and the head nurse, and we debriefed about his care. By the time rounds ended it was probably noon and I went home.
I kept myself busy during the day and went to bed exhausted around 10 o’clock, but sleep wouldn’t come. And that is how I found myself, at two in the morning, on Sherbrooke Street watching the cars whiz by on the Decarie Expressway. I had been reliving those moments over and over in my head. I think I finally got to sleep about four o’clock in the morning and then hauled myself in for eight o’clock rounds. I guess I looked pretty awful because the staff physician (a different one from the day before) pulled me aside after rounds and gently asked me what was the matter – although I’m pretty sure she knew. I told her about my midnight walk. She dropped what she was doing, we went for coffee and debriefed about the episode of the night before. She had heard about the case and, in fact, already had the preliminary autopsy report. We discussed my thought processes, my reaction, and the feelings that I was having. This was done in a gentle, supportive, non-judgmental way such that I was able to learn from the experience, understand my feelings, and carry on with my day.
I was recently reminded of this episode from my early career when I came across an article in Healthy Debate by Glauser, Taylor and Tierney. In the article, the authors talk about the “second victim”. The second victim is often the health care professional involved. This occurs when bad things happen to patients, sometimes avoidable, sometimes not, but often blame is ascribed to the health care provider. They point out how badly we support our colleagues in dealing with either avoidable or unavoidable negative outcomes and point out how necessary it is to have the opportunity for a nonjudgmental debrief when outcomes are poor or unanticipated. The impact on the health care provider can vary from a few sleepless nights to suicide. This article points out quite a number of studies illustrating the long-term impact of failure to recognize and support our colleagues.
How are we in family medicine doing in supporting the second victim? Hospitals tend to have a formal system for debriefing critical events, but in general we have not yet moved to that level of formal structure in family medicine. Many of us are lucky enough to work in supportive, empathetic teams where providing a non-judgemental environment to debrief about mistakes or near misses are commonplace. The simple fact that we work with our patients over months and years leads to closer relationships. When we work in an environment that adds another level of support from our peers and colleagues, we can go a long way towards mitigating the stress from bad outcomes.
How often do we take the time to ask our colleagues “how are you”, and really mean it? How often do we take the time to ask the next question and to be supportive? I know that in the clinical environment in which I work here in the Department of Family Medicine at the Michael G DeGroote School of Medicine, I feel incredibly well supported. There have been bad outcomes over the years, of course, but I’ve never felt on my own.
I’m incredibly grateful to that supervisor from many years ago who took the time to help me both understand and deal with the many emotions that arose as the result of that event. I learnt so much during that brief time, not only about clinical care but how important it was to understand my own reactions.
The final autopsy report was conclusive that nothing I could have done that evening would have made any difference to that man’s clinical course. While a reassuring report, by the time I received it, I was not a second victim, but a maturing health care provider.
Chair’s Corner is a regular feature from Dr. David Price, Chair and Professor in the Department of Family Medicine. It is a reflection and call to action around subjects of importance to our faculty, staff, residents and patients.