Episode #86 Primum Non Nocere But What Happens Next

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are going to talk about an important part of keeping patients safe during anesthesia care…and that is keeping the anesthesia professionals safe. A real threat to the health and safety of anesthesia professionals is Second Victim Syndrome.

But before we dive into the episode today, you’ve heard me recognize our corporate supporters on this show, but there’s another supporter who is absolutely essential – YOU! Every individual donation matters so much. Please visit APSF.org and click on the Our Donors heading and consider making a tax-deductible donation to the APSF.

This is a challenging and critical topic related to anesthesia patient care. Our featured article today is from the October 2021 APSF Newsletter called, “Primum Non Nocere But What Happens Next” by Stephanie Davidson. To follow along with us, head over to APSF.org and click on the Newsletter heading, 5th one down is Newsletter archives. Then scroll down and click on the October 2021 Newsletter. From here, you will scroll past several articles that will look familiar because we have talked about them recently on the podcast and then click on our featured article today. I will include a link in the show notes as well.  We have exclusive content from the author and I am going to let her introduce herself now.

[Davidson] “Hi, my name is Stephanie Davidson and I’m the director of quality for the HCA GME Residency in Las Vegas Nevada.”

To kick off the show today, I asked Davidson what got her interested in this topic. Let’s take a listen to what she had to say.

[Davidson] “The topic of Second Victim Syndrome or SVS is an emotion or feeling that I have experienced throughout my medical career that I did not understand or even know how to identify. It was thrust upon me one thousand-fold during the mass casualty shooting of 1 October in Las Vegas. I found myself struggling to leave the hospital in the days that did follow. I could not separate myself from the event. My nights were peppered with dreams of showing up late to help those in need. As debriefing set in, I found I struggled with those that were not present during the critical hours and seemed to just move on seamlessly. Simple comments such as ‘It’s so busy here today you can’t even image’ I took personally and left me feeling like I hadn’t contributed. As time moved forward, I was part of many critical debriefs from the local level to being part of the ASPR TRACIE Webinar. It wasn’t until my pediatric surgeon husband and I were asked to speak at various trauma conferences where SVS was included as a separate talk where I began to heal and understand the importance of the topic.”

[Bechtel] Thank you to Davidson for sharing such a personal story and insight. It’s now time to get into the article. Davidson starts off the article with her personal experience with second victim syndrome or SVS that stemmed from being in charge of the operating rooms that took care of over 200 trauma patients on October 1, 2017 during the Las Vegas Mass Casualty Event. One of the biggest takeaways from this event and other patient-related adverse events is that for the anesthesia professional and other members of the healthcare team, when the event ends, it may not be over. Davidson shares that this was certainly true for her following this event. I will read her statement now:

“The imprint this event left on me is indelible and every time I tell my story, the anxiety it produces gives way to a sense of healing after an emotional and psychological wrestling match.” (Davidson)

Now, let’s take a closer look at this history of Second Victim Syndrome. It was first described by Albert Wu in 2000 and then further defined by Scott and colleagues in 2009. It is the state of mind of a health care provider whose patient has experiences an unanticipated adverse event, medical error, or care-related injury. The patient is the “first victim” and the health care provider involved in the unanticipated adverse event, medical error, or care-related injury is the “second victim.” Second victims can be further identified since they are likely traumatized by the event and may take personal responsibility for the event and patient outcome. Second victims may have feelings of failing to take good care of the patient as well as questioning their clinical skills and knowledge base. It is critical to recognize SVS since the psychological trauma that occurs following an unanticipated adverse event and related negative patient outcomes leads to another victim from the event, the second victim, the health care provider.

Now, for a closer look at some of the literature on Second Victim Syndrome. Have you experienced second victim syndrome? It is common too with almost 80% of health care providers being involved in an adverse event or near-miss combined with an emotional impact following the event at least once over the course of their careers. Additional studies have reported the prevalence of SVS to be about 10.4-43.3% of providers following a traumatic experience. Another important consideration is patient safety related to system failures or provider related. Patient safety incidents occur in about 1 out of every 7 hospitalized patients and this may include near-miss events, adverse events, and medical errors leading to worse outcomes, patient harm, and death. There is definitely work to be done to improve patient safety in the hospital. When patient safety incidents occur, members of the healthcare team have an increased risk for developing post-traumatic stress disorder. What does second victim syndrome look like for the healthcare professional? The reactions are varied and individualized and may be emotional, cognitive, and behavioral with far ranging impacts to future patients, colleagues, families, and personally. Second victims may even believe that they are not deserving of being a second victim related to their perceived lack of contribution during a critical event. Davidson relates the story of a PICU nurse stationed at the double doors between the ED and the OR on the night of October 1st who hit the door plate throughout the night to open the doors and allow other team members to pass through. While she was not directly responsible for patient care at that time, she played a vital role and experienced emotional trauma from that night as well.

Recognizing and acknowledging Second Victim Syndrome is an important step for the second victims that may help with healing following the event. Significant emotional trauma may lead to physical symptoms including chest pain, headaches, poor concentration, hypervigilance, and sweating. Davidson suggests several coping mechanisms that may be beneficial following a significant event including the following:

• Returning to daily activities which includes exercise, reading, socializing, journaling, or findings one’s personal best.
• Interacting with family members who can provide comfort.
• Learning to process emotions and understand the experience.
• Finding and receiving help from friends and colleagues.
• Most importantly, knowing when to seek professional help.

Be on the lookout for these signs that you may need to seek out professional help:

• Dreams and thoughts with painful emotions that interfere with your daily activities
• Significant behavior changes noticed by family and colleagues
• Thoughts of hurting yourself or suicidal ideations

Everyone with second victim syndrome copes differently due to personal circumstances, past experiences, core values and beliefs, relationships with colleagues, friends and loved ones, and personal self-care. Intervention may be a necessary step for processing emotions and healing from the adverse event.  Another important consideration is resiliency which likely develops over time. Davidson describes it as learning to bend without breaking. Resiliency involves learning from the experience of the traumatic event and going through the process of recovery. In the immediate aftermath of an event, second victims may feel exhausted, dazed, numb, sad, helpless, and anxious. These feelings may be amplified over time as the second victim thinks about the event and outcome on repeat. Intervention can help to break this cycle and prevent long-term poor outcomes for the second victim of PTSD, depression, anxiety, suicidal thoughts, and alcohol or drug abuse.

Evaluating your personal experiences, can you think of a time when you were a second victim, when you may have felt responsible for an unexpected poor outcome, an adverse event, or a medical error? Healthcare professionals may be primed to feel this way given the values of compassion and the desire to help that led to a career in healthcare in the first place. The event does not need to be a mass casualty event to create second victims. It may be as simple as missing an IV placement or something that affects an individual patient such as missing a STEMI or any experience where healthcare professionals provided care to the best of their ability and knowledge, but there was an adverse event or poor outcome or medical error. Following this, personal protective coping mechanisms may kick in to help process the event and move towards recovery, but other times negative feelings of doubt, anxiety, depression, and denial and fear may take over. Questions that second victims ask themselves include the following:

• Does everyone know what happened?
• Will these feelings pass
• Will my reputation be irreversibly affected?

Let’s take a closer look at the literature related to SVS. First up, we have Kathy Platoni, a US Army Psychologist and survivor of the Fort Hood Massacre, whose area of expertise includes PTSD treatment and war trauma. Her contributions include programs to address combat stress control and she highlights the importance of debriefings and crisis management. Platoni reminds us that “trauma is so very unforgettable.” Next up, we have Barbara Van Dahlen who started the Give An Hour Program in 2005 to provide free mental health care for active duty, National Guard, and Reserve service members and develop a national network of volunteers to help care for acute and chronic traumatic stress-related conditions. A recent development has been the partnership between Give An Hour and #FirstRespondersFirst which provides mental health services for first responders during the Covid-19 pandemic.

As we begin to wrap up for today, let’s look at recovery from SVS.

• First, the second victim may experience negative feelings and a loss of control following the event.
• The negative impact may be mitigated by colleagues who can provide a safe place to debrief as well as ongoing care and prevent additional harm.
• Next, the second victim may replay the event on repeat and have difficulty focusing or concentrating
• Once again, colleagues may be able to help at this stage with supportive care.
• The downstream effects of the adverse event may continue with a case review, root cause analysis, morbidity and mortality conference, or litigation. This stage is hard and may require peer or professional support.
• The final step is for the second victim to move on and recover but this will look different depending on the person and may involve a change in practice, limited ability to practice, or leaving clinical practice.

Davidson describes the first anniversary of the October 1^st Las Vegas Mass Casualty Event at her hospital. There was a lunchtime memorial for survivors and caregivers with a goal of providing comfort and searching for meaning in the unspeakable terror of the experience. She writes: Such an event is a circle that never closes, a story without an ending– but we were united by the understanding that we, and life, must go on. We cried till we laughed. We told stories and took pictures, celebrated life and life lost. And in the end, we all walked out the door of the meeting hall, together, tattooed with that experience and the belief that we would go on.”

Second Victim Syndrome is an important consideration for all healthcare professionals interested in anesthesia patient safety since the demands on anesthesia professionals related to patient needs, practice demands, the hospital system, family requirements, and satisfaction scores are immense and can lead to burnout…and it is leading to burnout with higher rates in health care compared to any other industry. There is a call to action for anesthesia professionals to be aware of second victim syndrome, to recognize it, and work towards treatment and recovery.

We are going to hear from Davidson again. I asked her, What do you hope to see going forward and what do you envision for the future related to Second Victim Syndrome? Let’s take a listen to what she had to say.

[Davidson] “As we move forward, SVS should be addressed during the didactic teaching years. Educating our residents and ourselves to understand the coping skills necessary is essential to take on the heavy burden and heavy load that comes with medicine in the 21^st century. As I stated in my review article, whether dealing with a missed IV on a neonate, an MI in an adult, or any traumatic event, we need to assure ourselves, our loved ones, and our patients that we are trained and skilled in our art of medicine and the surrounding circumstances. These life skills can contribute towards maintenance of our mental health, strengthen interpersonal skills, possibly have an impact on the plague of burnout and could possibly impact the number of physician suicides. I’d like to thank the APSF for this opportunity.”

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Have you checked out the newest page on the APSF website? It is the Look-alike Drug Vials: Latest Stories and Gallery. I will include a link in the show notes and we hope that you will head over there to read about the latest alerts, check out the gallery of look-alike vials, read the related APSF articles, listen to the related podcasts, and consider submitting your own look-alike drug alert. You can help to share information and keep patients safe.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation