Every doctor remembers his or her first patient death.

Rachel Clarke, a junior doctor in the NHS, was exhausted and “punch drunk” from working a string of 14-hour days. Despite continuously harassed by her pager – summoning her to more ill patients – she started to assess a man who eventually died in her arms.

After the incident, there was no one to help or to talk to. Instead, she continued to put on a brave face – carried on and treated the next desperately ill person who needed her.

This is not an uncommon situation. Doctors often feel lost when they lose their patients.

“So much to process and make sense of, yet we don’t talk about it. Instead, we seek safe harbour in our respective duties and rituals. We document. We clean the body. We notify the organ bank. We rip off blood-streaked gowns and gloves and toss them into the garbage bins. We snap a fresh sheet over Kevin’s body and brace for the families to arrive,” illustrated Dr Jay Baruch, an associate professor of emergency medicine and director of the Scholarly Concentration Programme in Medical Humanities and Ethics at the Warren Alpert Medical School of Brown University.

He was detailing the ordeal after a particularly gruesome and unjust death of a young 20-year-old man who was ejected through the front windshield of his drunken friend’s car, as it rammed into a telephone pole.

“And we move on,” he added solemnly.

Emotional trauma needs to be taken more seriously

Particularly in emergency medicine practice, “moving on” is a culture that has been deeply embedded. There is no time to focus on any one activity for too long – let alone grief for the patient.

Doctors at the frontline of care often handle a mix of complex work-ups, procedures and conversations due to the need to care for a large number of patients.

The “move on” attitude however, is not without its perils.

“Despite attempts at bravura, emergency medicine providers, along with other frontline specialists, burn precariously bright when it comes to depression and burnout,” said Dr Baruch. “When physicians suffer, patients may suffer too.”

Apart from the extreme physical requirements, the emotional trauma doctors suffer would lead to a lack of quality healthcare – decrease in compassion, patience and comfort.

The depression and burnout has also driven many doctors to suicide. Most recently, in the UK, a junior doctor in his 30s was found dead at Musgrove Park Hospital, Somerset. In the past 18 months, the UK has witnessed at least three junior doctors who have taken their lives.

The case of Kimberly Hiatt


Kimberly Hiatt, a longtime critical care nurse at Seattle Children's Hospital, committed suicide in April 2012, seven months after accidentally overdosing a fragile baby. Photo credit: Lyn Hiatt
Kimberly Hiatt, a longtime critical care nurse at Seattle Children's Hospital, committed suicide in April 2012, seven months after accidentally overdosing a fragile baby. Photo credit: Lyn Hiatt

The burnout could also lead to physicians committing unwanted and unforeseen errors.

In September 2011, registered nurse Kimberly Hiatt realised she overdosed a fragile baby with 10 times too much calcium chloride at the Cardiac Intensive Care Unit at Seattle Children’s Hospital.

She immediately reported her error and in her 24-year career, this was the only serious medical mistake she had ever made. However, the 8-month-old Kaia Zautner died and Hiatt was placed on administrative leave – before being dismissed permanently.

Hiatt was then investigated vigorously. To satisfy the state nursing commission, she agreed to pay a fine, undergo a 4-year probation and include medication supervision to get back into her profession. She also aced an advanced life support course and qualified to function as an in-flight nurse.

She had many job offers. However, upon knowledge of her only record, she was rejected. Depression and isolation set in – she then committed suicide on 3 April 2012.

Hiatt was the “second victim” of medical mistakes – someone who has to live with the aftermath of making the mistake. The first is the patient who directly suffers from the preventable error.

The “second victim” – a common setting in healthcare

 

Dr J. Ravichandran presenting his lecture on “The Second Victim”, about the psychosocial effects of peers who have gone through disciplinary action.
Dr J. Ravichandran presenting his lecture on “The Second Victim”, about the psychosocial effects of peers who have gone through disciplinary action.

The “second victim” is a phrase coined a decade ago by Dr Albert Wu, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.

It highlights the reality that healthcare professionals, who commit errors, go through. Many are often traumatised, with reactions that range from anxiety and sleeping problems to doubt about their professional abilities, which could lead to suicide.

“It’s reported that 10 – 40% of second victim healthcare providers remain traumatised and suffer psychophysical effects, long after the adverse events have passed by,” remarked Dr J Ravichandran, past-President of the Obstetrics and Gynaecology Society of Malaysia (OGSM) 2016/2017 during a lecture at the 25th OGSM Congress, in Kuala Lumpur recently.

“Even in the near miss, when the outcome is acceptable… there are still issues with self-confidence, job satisfaction and the ability to continue to function at that level,” he added.

The obstetrics and gynaecology community has one of the highest rates of being implicated in medico-legal matters. As such, Dr Ravichandran urged healthcare professionals to provide peer support to second victims.

“We are also human; doctors are not God,” he reasoned.

“The impulse to keep moving is natural and invested with purpose and pride,” Dr Baruch explained, “But, what Kevin’s untimely death has taught me is that it comes with a cost.”

The realisation that the nobility of the “it’s what we do” attitude often serves as a simple cover up for those crushing experiences – ignoring the adversity of the psychosocial impacts that they have on healthcare professionals. “If we are stretched even more, then everything falls apart,” lamented Dr Clarke. MIMS

Read more:
Patient care may come with an emotional cost
“Drop Out Club”: Explore the alternatives – Part One
How death cafes can help medical students learn the art of breaking bad news

Sources:
http://www.mirror.co.uk/news/uk-news/doctors-here-save-lives-not-10953168
http://www.mirror.co.uk/news/uk-news/doctor-haunted-face-man-who-10880039
http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.WY1bJ1UjGUk
https://www.statnews.com/2017/08/02/emergency-medicine-trauma-doctors/