November 18, 1999 marks the date on which I was introduced to the full emotional impact of adverse medical events. At the time I was providing primarily orthopedic anesthesia and utilizing my fellowship training in regional anesthesia for a variety of procedures. Linda presented as my patient for a total ankle replacement and we decided to proceed with a general anesthetic combined with a nerve block (popliteal fossa) for post-operative pain control. The block was performed in the preoperative area using standard technique and was uneventful. As we were preparing to take Linda to the operating room, Linda suddenly began to experience confusion, which rapidly progressed to a grand mal seizure. After calling a Code, we watched in the next minute as Linda went into v-fib cardiopulmonary arrest. In spite of full resuscitative efforts using BLS/ACLS, we were not being successful in restoring her cardiovascular function and we recognized that we would have to take extreme measures to save her. By synchronous good fortune, a cardiac operating room had been full prepped and was completely staffed to receive an ICU patient. We took the room and transferred Linda to the operating table; within 35 minutes from the onset of the event, Linda was connected to a bypass machine via a median sternotomy. After a couple of minutes on bypass, her cardiac rhythm was restored and she was successfully weaned off of the bypass machine and taken to the cardiac ICU an hour and a half later.
As clinicians we are trained to suspend our emotions in order to function effectively in crisis situations, and this had certainly stood me in good stead on this day. What became very evident to me, however, was an appreciation that we as care providers are not very well trained to deal with the emotional aftermath of such adverse events, nor is the healthcare system designed so provide support around these events. This became profoundly personal when, in trying to take responsibility for my action by communicating with the family, I was met by Linda’s husband with an unexpectedly intense emotional reaction for which I had no training to cope with. Further, I was discouraged to communicate in any manner with the patient and family by hospital administration and by my physician colleagues out of medical-legal concerns. The wall of silence that was quickly erected extended to preclude any discussion of the event with my clinical colleagues, again out of fear of litigious consequences and awkwardness. I found myself isolated and the event was rapidly buried under the continued flow of patients coming to the OR, as though nothing unusual had happened. The message effectively was “bad things happen in medicine, move on.”
Out of my sense of integrity and compassion, I refused to acquiesce to the system’s expectation of silence with the patient and family. After numerous blocked attempts to communicate directly with Linda during her ten-day admission Linda was discharged home. I was devastated at the lost opportunity and took it upon myself to write her a personal letter of apology and an invitation to communicate with her at any later time if she so desired. A phone with Linda followed six months later and marked a transformative pivot point in personal healing and the beginning of my commitment to remodel the way that healthcare responds to adverse medical events.
Care providers learn very early in their training to distance themselves from the emotional content of patient interactions. We learn that empathy must replace sympathy so that we can maintain our clinical focus and our mental health. We learn and experience that while adverse events occur frequently, that they are unacceptable and a mark of failure (“first, do no harm”). We learn that to acknowledge responsibility in an adverse event is a set up for litigious retribution. We learn that seeking support from mental health professionals is a sign of weakness. In short, we create a culture that expects care providers to be lone super heroes and a healthcare system that supports this belief.
I don’t think that I expected support from my colleagues or from my institution following my adverse medical event. The shame, the lack of confidence, the guilt and the vulnerability were mine to deal with in isolation. That’s the way the system was set up. I gradually began to realize that my colleagues were also feeling the same way that I was following adverse events that they experienced and that this too was taking a toll on their passion for medicine and on their personal relationships.
The focus of MITSS for care providers is to create awareness that the impact of adverse medical events extends beyond patients and families and that support services need to be accessible for all. I have been working in my healthcare institution to develop and to implement a Peer Support Team model that provides voluntary, confidential access to emotional support in an environment that is comfortable and safe. It was formally launched in July 2006. Physicians speak with trained fellow physicians, nurses speak with nurses and residents speak with residents; conversations are one-on-one or in groups, and those that would benefit from and are willing to utilize formal support are seamlessly connected to this next level of care. We have already seen a remarkable shift in culture and a greater sense of team spirit emerge from this support process. Our goal is to make this model of Peer Support Teams accessible to other healthcare institutions for implementation.
As care providers we need to remind ourselves that we are human and that adverse medical events will impact our lives, both professionally and personally. It is important for us to suspend emotions during many clinical situations that we face and it is equally important to remember that this suspension should be temporary: We need to be able to decompress ourselves to sustain our passion for what we do and our compassion for those that we care for. I hope that MITSS will serve to promote support services for you and your institution through the Peer Support Team model and that you will find the other MITSS resources and services helpful as your careers continue.
With love and respect,