I pushed the respiratory therapist aside, took a deep breath, and slid the laryngoscope into her mouth. Three minutes earlier an overhead page had called me to my first code, and here, for the first time without an attending watching over my shoulder, I was intubating this young woman who, for reasons as yet unknown to me, had arrested in her hospital bed. To my utter relief and sheer delight, her vocal cords were in clear view and I passed the endotracheal tube with ease. After confirming placement with the CO2 detector, and listening to both sides of her chest, I secured the tube and wiped the sweat from my brow. For 1 moment, I felt great relief, even pride. Well done, I thought to myself, and prepared myself to see her come back to life.
My sense of satisfaction, however, soon turned to terror as I watched her turn blue despite my successful intervention. My heart was racing. I listened, once again, to her right lung and her left, her right lung and her left, her right lung and her left: bilateral and equal. I listened to her stomach: nothing. I checked again for exhaled CO2: present. I finally resorted to taking another look at her airway: the tube was between the cords. I watched as the internal medicine intern pounded on her chest, and listened as the oncology fellow called for another dose of epinephrine… atropine… now bicarbonate. But not even 360 joules of electricity could help her. She had become a blue shell and finally there was nothing left to do for her. As the fellow called the code, I dropped my head, knelt down to the floor to collect my instruments and walked away in defeat.
Within a few minutes, I returned to my duties of caring for the patients in our PACU; making rounds, checking X-rays, taking reports from fellow residents. Looking back, I realize that I felt obliged, as a PGY-2, to be perfectly capable of resuming “business as usual.” Despite my every effort, however, I was overcome with grief, guilt, and anxiety. I could not get the image out of my head of this young woman’s last moments and could not help but wonder if there was, perhaps, something I did or did not do that contributed to her death. One of our attendings happened to be walking through the PACU and noticed the tears welling in my eyes that I was desperately trying to conceal. For God’s sake, Farnaz, don’t cry in front of the patients and nurses… Get a grip, I told myself on his behalf—I was sure he wanted to. But, instead, he guided me to a small corridor that afforded a bit more privacy and offered me a fatherly hug and an understanding ear. He listened as I recounted our resuscitative efforts and explained to him all of the questions and fears that were racing through my mind. He conveyed extraordinary compassion and empathy. I knew he understood what I was feeling and that he cared. Both verbally and non-verbally, he spoke volumes. His healing presence was calming and I was finally able to control my tears. I took a few minutes to wash my face and clear my thoughts, and went back to work.
The Potential of Compassion
Almost a year later, I look back at that experience and marvel at the boundless potential of compassion. Had it not been for the empathic, caring, and wise counsel of my attending at a moment in time when I most needed it, that same Code Blue would have been just one of many stressful and traumatic experiences, fostering self-doubt, cynicism, and burnout. It would have served to make me a little less caring, less feeling, and less fulfilled in my capacity as a physician. Instead, that same experience, as painful as it was, proved to be transformative, in a positive way. I continued to mourn the death of this young woman for quite awhile. Rather than impinging on my ability to care for my patients, as we are often led to believe such sentimentality would, I found my curiosity enhanced, my patience expanded, my energy revitalized. Everything meant more to me and I, in turn, paid more attention to how I greeted my patients, how I touched them, how I positioned them on the operating table, and how I managed them medically. The need to learn, by reading or listening, as much as I could about human physiology, pharmacology, and disease processes suddenly seemed urgent. The very meaning of my work gained new dimension, and the countless sacrifices I make as a resident now seemed to mean more than simply a means to an end. My work began to feel less like a job and more like a calling. Paradoxically, this experience allowed me to reconnect with the humanistic dimension of our work. I attribute much of this to having had the opportunity to debrief with my attending.
In a broader context, this experience also alerted me to the potential negative impact that the death of a patient might exert on a resident. I started talking to fellow anesthesiology residents who were unfortunate enough to have experienced the intraoperative death or serious injury of a patient, asking them about their experiences and the psychological impact the events had on them. As varied as their personalities, specifics of their stories, and the details of the aftermath were, two things were made clear to me: the intraoperative death or serious injury of a patient is an extremely stressful event for a resident, and the opportunity to speak soon after the incident, in one capacity or another, with an attending who acknowledged and cared about the impact of the stress on the resident, was extremely constructive.
The Stress of Anesthesiology Residency: Disasters and Their Aftermath
Anesthesiology is commonly perceived to be a “high stress” subspecialty. Our disproportionate representation among physicians who commit suicide and physicians in drug rehabilitation programs may be a marker of this.1,2 While only 3-4% of all physicians are anesthesiologists, anesthesiologists comprise between 9-13% of physicians treated in substance abuse programs.2,3 A survey of 133 United States anesthesiology training program chairs conducted between the period of 1990-1997 revealed an incidence of known drug abuse of 1% among anesthesia faculty and 1.6% among anesthesiology residents.1 Residents seem to be particularly vulnerable, with several studies finding high rates of alcohol and drug use. Anesthesiologists are also at greater risk for suicide. The risk to anesthesiologists of drug-related death is greatest in the first 5 years after medical school.2 While the proposed explanations for these alarming and disturbing trends have yet to be elucidated, they do indicate, I believe, not only the high level of stress in our specialty, but also, and perhaps more importantly, our paucity of skills for coping with this stress in a healthy, adaptive manner.
The ability to stay calm and remain highly functional in stressful circumstances is one of the key skill sets needed to practice anesthesia effectively. We, as anesthesiologists, take pride in our critical care skills and our mastery of life-saving techniques and protocols. Further, our ability to remain levelheaded and calm when things are going awry is paramount. Where we are lacking, however, is in skills dealing with the aftermath of such “disasters.” For, “the focus of training in anesthesia is concerned with the avoidance of disasters, rather than the management of their aftermath.”4 Our lectures, literature, and simulations rarely, if ever, address the need for developing skills needed to cope with the stress of medical catastrophes such as the intraoperative death or injury of our patients.
Several studies indicate that the majority of practicing anesthesiologists will experience the intraoperative death of 1 patient in the course of their careers. I believe that residents, lacking the benefit of clinical expe
rience and the confidence that years of providing safe and successful anesthetics confers, and given the plethora of added anxieties and pressures of residency, are particularly prone to the psychological stress of such events. In a cross-sectional study of 188 doctors working in 2 academic hospitals in the United States who cared for 68 patients who died, junior residents reported needing significantly more emotional support than attending physicians after the death of their patients.5
The Need for Support
Many American medical societies, including the American Academy of Pediatrics, for example, have put forth statements acknowledging the impact of patient death on physicians, and the importance of addressing the concerns and needs of the physician after the death of a patient.6 Our colleagues in the UK have acknowledged the potential impact of perioperative death on the anesthesia provider, publishing guidelines for dealing with the aftermath of anesthetic catastrophes. In 2005, The Association of Anaesthetists of Great Britain and Ireland advised against underestimating the psychological impact on staff following the death or serious injury of an operative patient. In the document, they list ways in which “a catastrophe may affect you personally” and provide suggestions for supportive actions to be taken should a colleague experience an intraoperative death.7
Given the heterogeneity of circumstances surrounding patient deaths and of anesthesiologists’ personalities and needs, not every anesthesiologist or anesthesiology resident will have the same needs after an adverse event. Further, there is a growing body of literature questioning the efficacy of single-session psychological interventions such as Critical Incident stress debriefing.8 Nobody likes to be force fed, even when what is being forced is meant to help you. At the same time, some form of organizational support should be provided, I believe, to all anesthesiologists, but especially to residents who experience an intraoperative critical incident. Without the opportunity for open and honest discussion, “feelings of incompetence and isolation and psychological distress such as depression or even symptoms of post-traumatic stress disorder such as sleep disturbance, nightmares, irritability, and problems concentrating, which may even lead to an inability to work, are far more likely.”8 Some time out of the OR may or may not be needed. A demonstration of support and understanding from the institution may be very helpful after an adverse event. In some situations, sitting down with the patient or family to discuss what happened (a practice previously discouraged or even forbidden by the liability insurer) might be of great value. But at the very least, the opportunity to discuss what happened in a confidential, safe, supportive, and blame-free environment—whether it be a team debriefing session including all involved OR staff or simply a discussion with a colleague or mentor over a cup of coffee—would be an easy initial strategy for addressing this important issue. We need to reach a point where every junior resident who experiences a poor outcome despite his or her best efforts will get the kind of compassionate support that I received.
Dr. Farnaz Gazoni is an anesthesiology resident at the University of Virginia, in Charlottesville, VA.
- Booth JV, Grossman D, Moore J, et al. Substance abuse among physicians: a survey of academic anesthesiology programs. Anesth Analg 2002;95:1024-30.
- Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology 2000;93:922-30.
- Talbott GD, Gallegos KV, Wilson PO, Porter TL. The Medical Association of Georgia’s Impaired Physicians Program. Review of the first 1000 physicians: analysis of specialty. JAMA 1987;257:2927-30.
- Aitkenhead AR. Anaesthetic disasters: handling the aftermath. Anaesthesia 1997;52:477-82.
- Redinbaugh EM, Sullivan AM, Block SD, et al. Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital doctors. BMJ 2003;327:185.
- Serwint JR, Rutherford LE, Hutton N. Personal and professional experiences of pediatric residents concerning death. J Palliat Med 2006;9:70-81.
- Catastrophes in Anaesthetic Practice—dealing with the aftermath. The Association of Anaesthetists of Great Britain and Ireland. 2005. Available at: http://www.aagbi.org/pdf/catastrophes.pdf. Accessed on March 15, 2006.
- Manser T, Staender S. Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure. Acta Anaesthesiol Scand 2005;49:728-34.