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Cause for Pause After a Perioperative Catastrophe: One, Two, or Three Victims?

Martin, Timothy W. MD, MBA*; Roy, Raymond C. MD, PhD

doi: 10.1213/ANE.0b013e318214f923
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From the *Division of Pediatric Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Timothy W. Martin, MD, MBA, University of Arkansas for Medical Sciences, Division of Pediatric Anesthesiology, AR Children's Hospital, 1 Children's Way, Slot 203, Little Rock, AR 72202. Address e-mail to martintimothyw@uams.edu.

Accepted February 7, 2011

Anesthesiologist's Lament

Oh my god, what happened? I need to know.

Did I miss a sign? My response, too slow?

If I was distracted, poorly prepared,

It was not his fault. He should have been spared.

If Lachesis measured a longer thread,

What changed his fate? What? And why is he dead?

When unbidden Atropos came to call

Over our lives she cast her black pall.

Will I see his shroud in another's face?

In waking dreams am I doomed to retrace

The steps untaken, the shock, even shame

And tormenting fear that mine is the blame?

—R. C. Roy, 2011

Most practicing anesthesiologists during their careers will be involved in at least one perioperative catastrophe that turns a patient into a victim. Although the details and responses may vary, the anesthesiologist responsible for the patient who has suffered the unexpected perioperative death or severe adverse event resulting in permanent disability invariably manifests a range of emotional and psychological responses such as those described in the Anesthesiologist's Lament (R. C. Roy, personal correspondence). Guilt, anger, depression, repetitive reliving of the event, and loss of confidence are included in the umbrella of symptoms that comprise acute and posttraumatic stress disorders (Tables 1 and 2) that sometimes become so severe that the affected anesthesiologist may contemplate a career change or even suicide.1,2 In essence, the anesthesiologist becomes the second victim of the catastrophe.2,3 If vigilance is reduced as a consequence of depression or symptoms of the acute stress disorder, then patients subsequently anesthetized by the affected anesthesiologist may become third victims.46 In this issue of Anesthesia & Analgesia, Gazoni et al. report the results of a large survey of active and resident members of the American Society of Anesthesiologists that assessed the impact of perioperative catastrophes on American anesthesiologists.7 Their findings confirm the high likelihood that every anesthesiologist will be involved in a perioperative catastrophe during his or her career and provide strong evidence for second and third victim concepts.

Table 1

Table 1

Table 2

Table 2

The Gazoni et al. study revealed a number of notable findings, some predictable and others less so. A carefully designed questionnaire was mailed to 1200 randomly selected active and resident physician members of the American Society of Anesthesiologists, of whom 659 (56%) responded. Eighty-four percent of the responders acknowledged involvement in at least one unanticipated death or serious injury of a perioperative patient over the course of their careers. When queried about the emotional impact of a “most memorable” perioperative catastrophe, >70% experienced symptoms such as those listed above, and 88% reported requiring time to recover emotionally from the event. Twelve percent reported having considered a career change in the aftermath of the catastrophe. Interestingly, 67% believed that their ability to provide anesthesia care was compromised in the immediate aftermath of the case (nearly one third indicated a substantial degree of compromise), yet only 7% reported having been provided time off immediately following the event to collect their thoughts and begin personal recovery. Five percent admitted to the use of alcohol or drugs as a result of the event.

In most hospitals or anesthesiology groups (and often both), after a serious adverse event or unexpected death, there are reporting and review processes that must occur. These may take the form of morbidity and mortality conferences (single specialty or multidisciplinary), root-cause analyses, or either internal or external peer reviews of the case and event. Often there are several different types of investigation and review undertaken simultaneously by various individuals or entities. Their purpose is to identify and correct process or system failures or weaknesses to prevent recurrence of the event with other patients or health care providers. But rarely is there a formal wellness advocate for the anesthesiologist who was closely involved with, or perhaps responsible for, the patient at the time of the catastrophe. Is it appropriate for the anesthesiologist to immediately return to clinical duty and the care of other patients on the same day or within the same week of a serious event? Or is the anesthesiologist transiently “impaired” during the immediate aftermath of a catastrophe? Are follow-on patients being exposed to unnecessary risk if they are cared for by such a physician? Could these patients also become the third victims of an unanticipated medical catastrophe? What can or should be done to assist the anesthesiologist in progressing through to a healthy recovery following such an event?

Nineteen percent of respondents to the survey indicated that they had never fully recovered from the perioperative catastrophe. Arguably, then, these events are of the same magnitude as other major life events such as death of a close friend or relative, divorce, or exposure to some natural disaster.8 Horowitz describes 6 phases of response to stressor events: (a) the event itself; (b) outcry; (c) denial; (d) intrusion; (e) working through; and finally (f) completion.9 The phases of outcry, denial, and intrusion may be marked by excessive reactivity manifested as panic, irrational thinking, and types of maladaptive avoidance, such as depression, drug or alcohol use, or suicide. Intrusions are cues, reminders, or memories of the serious event that may induce dread and fear and distract the individual from present duties and activities such as the care of other patients. If the working-through phase is blocked, the result may be psychosomatic reactions and various maladaptive behavior disorders, and if the phase of completion is not reached, the result may be a state known as personalityconstriction with inability to act or love. Any of these represent serious outcomes for the anesthesiologist if not treated appropriately!

Scott and colleagues described the natural history of recovery for the health care provider second victim following adverse patient events.2 They conducted and analyzed semistructured interviews of 31 second-victim health professionals for common patterns or themes, and concluded that the postevent trajectory of recovery is predictable and consists of 6 stages of recovery: (a) chaos and accident response; (b) intrusive reflections; (c) restoring personal integrity; (d) enduring the inquisition; (e) obtaining emotional first aid; and (f) moving on.

Anecdotally, and as reflected in the results of Gazoni et al.'s survey, it is common practice for an American anesthesiologist who has been involved in a perioperative catastrophe to immediately resume clinical activities with other patients, despite the expressed preference of survey respondents to be relieved of clinical duty for at least the remainder of the day of the critical incident. In addition to the emotional and psychological concerns and processes described above, there are typically a number of added obligations and duties that the anesthesiologist must attend to prior to resuming care of other patients. These include completing contemporaneous medical record documentation of the event, meeting with the patient or family of the patient to discuss the event and, if applicable, providing disclosure of any medical errors, and participating in any immediate investigation or debriefing following the event. Finally, the possibility exists that the harmful event was at least partially, if not largely, due to decreased vigilance and an inability to concentrate—in short, due to some type of physician impairment, whether due to a physical illness, substance abuse, or some other mental health disorder, such as depression.4,5 In the immediate aftermath of an unanticipated catastrophe, the question should be asked whether physician impairment in any form might have played a role in the disaster, and appropriate assessment should be undertaken.

As is the case with all good research, the large survey conducted by Gazoni et al. raises many questions and suggests new imperatives. First, health care organizations and anesthesiology groups must seriously review, and likely change, the practice of allowing anesthesiologists and other medical professionals to return immediately to the clinical care of other patients following a perioperative catastrophe. This is often difficult in today's medical economic climate with its attendant high production pressure and demand for rapid turn-over between cases, but the real possibility exists that follow-on patients may be put at increased risk of an adverse outcome themselves, i.e., becoming third victims. It must be emphasized, however, that the authors are unaware of any study of the performance of anesthesia providers in the aftermath of a catastrophic perioperative event. And practically, as indicated above, the anesthesiologist almost always has mandatory unfinished work relating to the index case to complete. Second, institutions need to develop formal screening mechanisms to assess anesthesiologists (or physicians and nurses generally) who have been involved in such disasters and triage them to appropriate mental health resources to optimize the chances of healthy and nonprotracted recovery. The specter of liability of the employer being responsible, not for the catastrophic event, but for the failure to monitor the health of the second-victim health care provider and provide timely treatment is real.10 Third, organizations must remain vigilant for the possibility of long-term psychological impairment and substance abuse in personnel following perioperative catastrophes. Increased education concerning the professional and personal impact of serious unexpected adverse patient outcomes must be provided to anesthesiology residents in training and practicing anesthesiologists, both in academic and private practice settings. Specific attention should be provided to develop and inform anesthesiologists and anesthesia residents of resources, both formal and informal or social, that are available to assist and, if necessary, treat them as second victims following such catastrophes. Fourth, existing critical incident or case review processes should be reviewed for efficacy and the contribution they might make toward the less-than-optimal recovery of the anesthesiologist following a perioperative catastrophe.11 The emerging interest in prompt and full disclosure of medical errors (if present as part of the adverse event) should be assessed for its impact, positively or negatively, on the recovery profile of anesthesiologists.

Our national pastime of baseball differs from the society that spawned it in one crucial way: The box score of every baseball game from the Little League to the Major League, consists of three tallies: runs, hits, and errors. Errors are not desirable, of course, but everyone understands that they are unavoidable. Errors are inherent in baseball, as they are in medicine, business, science, law, love, and life…. In the final analysis, the test of a nation's character, and of an individual's integrity, does not depend on being error free. It depends on what we do after making the error.12

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Disclosures

Name: Timothy W. Martin, MD, MBA.

Contribution: This author helped write the manuscript.

Attestation: Timothy W. Martin approved the final manuscript.

Name: Raymond C. Roy, MD, PhD.

Contribution: This author helped write the manuscript.

Attestation: Raymond C. Roy approved the final manuscript.

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REFERENCES

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