As I reflect on my 17-year career since fellowship training, I can recall a dozen or more sentinel events. At least six were particularly devastating and profoundly eroded my mental health and contributed to my burnout. Four occurred during the first decade of my career, when I had no awareness about burnout or well-being. In the past seven years at my current health system, I have experienced two more. Serving in leadership roles as division chief and surgeon-in-chief did not shield me. I have only heard of the term “second victim” within the past two years.
Explore This IssueApril 2020
Second Victim Syndrome
First coined by Dr. Andrew Wu in 2000, “second victim syndrome,” as described in a KevinMD article (2019), involves “suffering that the healthcare provider experiences as a result of the psychological trauma the event causes. The emotional effects of second victim syndrome should not be understated. Symptoms of anxiety, depression, guilt, and loss of confidence are commonplace.”
But it’s more than that. I have experienced what must be similar to post-traumatic stress disorder, even if I have no frontline military or war experience.
I received a call from an outside ED one Wednesday morning, around 8:30 during a busy clinic day with 30 patients scheduled. “Your patient, “xxx,” has been pronounced,” the person said. I remember repeatedly asking, “Excuse me, I don’t understand. What do you mean “pronounced?” The voice on the other line stated that a five-year-old, on whom I had performed a T&A two days prior, was brought in by paramedics, pulseless and unable to be resuscitated. “Are you sure?” I asked repeatedly. I knew this child very well. I had trached him at six months of age for severe laryngomalacia, and he had been decannulated for over three years. He had undergone routine T&A for sleep-disordered breathing from severe tonsillar hypertrophy. His grandmother, who was his legal guardian, had found him in bed, cold and breathless, without any signs of bleeding or reason for the inconceivable death.
I still remember collapsing with the phone in my hand, crying hysterically. The first person I called was the one partner that I was closest to in the group. He tried to console me over the phone. My nurse asked me if I wanted to cancel the clinic. My answer was simply “no.” After all, the idea of canceling patients was not acceptable to me, even when in shock. I managed through that day somehow, holding back the tears.
Two days later, I arrived by 6:45 a.m. to about 15 ambulatory cases. There were at least seven T&A cases. I remember sitting curled up in the corner of the small physician lounge, crying and shaking uncontrollably, unable to fathom how I could ever perform another tonsillectomy again. If death was possible after a routine operation, I was paralyzed by the reality and implications of the rest of my career as a pediatric otolaryngologist. My anesthesia colleague pulled me off the floor and gently asked me if I wanted to cancel my cases and go home. I chose to stay, again. Cancelling any patient was not acceptable; stopping for any reason, because I was not well, was at that time not a possibility I could understand. Patients and families can’t be let down. This was not their “problem.” I completed all cases that day but recall my hands shaking with every tonsillectomy. I attended the funeral of my patient that Saturday, and had the pastor and others come up to me and say, “Oh, you’re the surgeon.” Perhaps it was paranoia after days of insomnia, but I think I heard whispers as his family and friends pointed at me. I was numb for weeks, then months. I was afraid with every tonsillectomy case.
I can’t remember the exact timing of my next sentinel event. It was another routine outpatient T&A on a healthy 16-year-old who was the daughter of an acquaintance. About one week post-op, I received a frantic call from the father that she was bleeding so briskly that as they tried to get her in the car to go to ED, she lost consciousness. I instructed them to call 911 and to go to our children’s hospital, as I would meet them there. As I rushed onto the freeway, I received a call from the paramedics that they needed to go to the closest regional trauma center due to the severity of acute bleeding.
Three physicians transported her to the OR, with the ED physician using a tonsil sponge to apply direct pressure to her throat. The adult ENT who covered that ED and the anesthesiologist transported her quickly upstairs to the OR, while I watched helplessly next to her father. Within a minute, OR nurses came running out asking for me to scrub in.
Awake tracheostomy. Seven units of RBC transfused, with Hgb still at 4. Twenty-two units of platelets. Three doses of factor VII. Repeated attempt to suture left inferior fossa resulted in nothing but continuous arterial bleeding. There was blood everywhere. Finally, ligation of the external carotid (answer from one of my four oral board questions in 2002) stopped the bleeding. I rode in the back of the ambulance, holding on to her fresh tracheostomy during transport to the children’s hospital where I was staff.
She survived. I did as well, barely.