I was on Twitter earlier exchanging tweets in response to my post Doctors Make Mistakes. Someone asked me if hospitals provide time to debrief when errors happen. Another said the debriefing should also deal with emotional reactions to what happened. This conversation reminded me of an event some years back.
A young female in her 20’s with aplastic anemia was admitted to the hospital. The plan was to transfuse with red blood cells and platelets and to send her home once her blood counts were acceptable. This was not her first admission for transfusion. She was stable and the only worry then was where to get the blood products as blood donors were needed.
One moment she was sitting on her bed talking with someone and the next she had collapsed and needed intubation. This involves “the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway (Wikipedia).”
Image credit: http://commons.wikimedia.org/wiki/File:Endotracheal_tube_colored.png
To insert that plastic tube in the airway, the doctor has to use a laryngoscope. I don’t know if you can see it in the picture below, but near the end of its blade, there is a small light. This enables the doctor to see down the patient’s airway as he is inserting the tube. And that’s where the problem began.Image credit: http://en.wikipedia.org/wiki/File:Macintosh_Blades.jpg
The doctor in charge of the patient was a first year medical resident doctor (It takes three years of residency to complete internal medicine training). I don’t know how many intubations he had done before but he was first on the scene. When he tried to use the laryngoscope, he found out that the light at the end of the blade would not light up! The nurses gave him the spare laryngoscope but its light was also busted. Another nurse had to run to the next ward to borrow a laryngoscope. While all this was going on, they were bagging the patient with oxygen through a mask but she was turning blue. Finally, with a working laryngoscope, the doctor was able to intubate her.
After some tests, it was determined that she had suffered a spontaneous massive brain hemorrhage on account of her platelet count being so low. Despite everyone’s best efforts, she eventually died.
The resident doctor was understandably upset. He filed an incident report against the nurses. He reasoned it was their job to make sure the laryngoscopes were working. He was withdrawn and silent at rounds. His senior medical resident gave him a pat on the back and told him it was nobody’s fault and that this was not the first case of aplastic anemia he had seen with sudden bleeding in the brain. There was no way of knowing even if the intubation had gone smoothly that the patient would have been saved.
There was no further debriefing or discussion of the event. The resident doctor quit the next day. I heard he transferred to a radiology residency.
How do doctors react to a patient’s death? In this paper by Redinbaugh et al, Doctors’ emotional reactions to recent death of a patient: cross sectional study of hospital doctors, data was gathered using a semistructured interview and a self-administered questionnaire.
A quote from the results in the abstract –
Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient’s death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support.
I was bothered by these statements! I currently serve as a residency coordinator under the training committee for third year internal medicine residents. Deaths are discussed, but usually in the context of a medical audit. Audits have more to do with academic reasoning, going over a patient’s case, looking at therapeutic options missed and determining the cause of death; and less to do with handling emotional reactions. Had the senior medical resident in the story been “hardened” by his previous experiences with dying patients? When he was a first year resident, had his senior resident also given him just a pat on the back when a patient had died? Did the attending physician ask why the first year resident had quit?
A quote from the paper’s conclusions –
The attending physicians in charge of the learning of their interns and residents do not often discuss these strong emotional responses. This conveys a message about how death is to be handled and potentially isolates learners who could benefit from having an opportunity to receive a seasoned perspective on what it is like to care for a patient who dies. A conspiracy of silence toward emotions can potentially cause trainees to develop maladaptive coping patterns that lead to burnout and other forms of emotional distress.
This is definitely something to think about as new trainees come in this January.
Redinbaugh EM, Sullivan AM, Block SD, Gadmer NM, Lakoma M, Mitchell AM, Seltzer D, Wolford J, Arnold RM. Doctors’ emotional reactions to recent deaths of a patient: cross sectional study of hospital doctors. BMJ 2003; 327:185
When I read such pieces written by physicians, I gain another small measure of hope that health care can regain the “care” piece that has been missing for at least my several decades of participation.
A few remarks, from head to heart:
1. it is possible that the resident recognized that, being who he was, in the reality of the medical culture where he was, he would be unable to function well there and so transferred to one that might ultimately be better for him.
(For example, in my former field, there are psychologists who do nothing but testing — and I was happy some of them were not with me in the clinic, actually doing psychotherapy, but they were great on the team nonetheless.) We each have our strengths and weaknesses, and then we put ourselves into a work context: it’s a fit, or it isn’t, or we bloody our heads against the walls or each other trying to make it a fit.
Any supervisor/mentor is doing a trainee a favor by helping them realize their best fit and best work. That might mean supporting grief (by modeling tolerating the feeling oneself, which often can be accomplished simply by listening or sitting with, silently); it might mean suggesting another specialty. It’s the teacher’s call how to do that best.
2. Including a discussion of a doc’s emotional reactions (if indeed s/he is aware of, or willing to disclose them) in my own opinion should be an automatic part of any “debriefing” or “M&M” meeting. The irony is that the field treats its own so inhumanely throughout training, from what I have heard and read — it is small wonder some of us as patients receive “robotic” treatment. “First, do no harm” should apply to the docs.
It takes greater strength and courage to allow oneself to feel emotional discomfort and pain than it does to clamp it off, shunt it away, cauterize it. (Then you might wind up in MY office, or an addiction rehab center, or on the ledge…)
3. And last, these days I keep thinking of a few lines that were in fact written by an MD who is also a novelist — Tess Gerritsen. When I read the following lines from her 2001 novel “The Surgeon” the truth of her words were a gut blow to me, and I think of them often as there has been much suffering and death in my world lately:
“In silence they faced each other in the gray light through the window,
and he thought: No kiss, no embrace, could bring two people any closer
than we are right now. The most intimate emotion two people can share
is neither love nor desire but pain.”
I had never seen it that way before.
So when I reflected on the odd impact of her words, I began to realize how incredibly complicating that odd intimacy is, and how incredibly powerful.
Doctors and other healthcare providers especially in certain specialties have to face this pain frequently, almost constantly, and I wonder how many of them realize the profound depth to which they can be affected without really quite “getting” what has “gotten to” them. (Then I realized that was something that, in fact, psychotherapists specialize in, but it so rarely is so openly discussed.)
Expecting a doctor to “shake off” such an incredibly intimate, painful experience, especially followed by a death is — IMO — absolutely inhumane.
If we want better health care, we need better treatment of the treaters-in-training.
For those of you in the difficult position of teaching — you will have the gratitude and appreciation of patients who will never know how hard you worked to make their doc, the one they do thank, a good one.
May that, at least, be enough, although I believe you deserve so much more.
Thanks for your insight Si. Looking back, I realize your comment is true – “I wonder how many of them realize the profound depth to which they can be affected without really quite “getting” what has “gotten” to them.” I hope others are brought to some kind of realization too.
Was the incident report followed up? If my assumptions are correct with regards to the hospital and ward, I experienced 2 similar incidents in the area wherein the resources happened to be inadequate (defibrillator not charged up, no stock of lubricating jelly) ending with the patients dying (though admittedly they had poor prognosis and clinically deteriorating, in the first place). This got some of my service-mates/duty-mates and I, frustrated for quite a while. How do we deal with systems failure, or repeated inadequacies of some members of the healthcare team, which inadvertently led to the demise of a patient? We do audits and morning endorsements among us but how about the other non-physicians in the team? I also disagree with the 3rd-year resident’s non-blaming words of comfort. Isn’t it part of our mandate to deliver the standard of care even if such intervention offers a low chance in saving/extending such life? Or am I just being too idealistic?
On Twitter, I had the opportunity to ask some nurses if it was the nurse’s fault that the laryngoscope bulbs were busted. One nurse told me that indeed it is the duty of the ward nurse to check the laryngoscopes in the crash cart; however, even if it was checked, old bulbs can still fail after checking out to be ok. Having two laryngoscopes fail though brings the system of checking into question. The event I narrated here happened more than a decade ago Gab so I do not know what happened to the incident report. From the comments on Twitter, it was also brought up that debriefing should also include the nurses. I realize that the story is incomplete. We have no way of knowing what the nurse (whose duty it was to check the laryngoscopes in the crash cart) felt about the incident. Did he also quit like the resident? Was he also guilt-stricken even if he was perhaps not at fault? You are correct in saying that we should deliver standard of care always, to the best that we can. While I personally feel that the third year resident’s comments was somewhat lacking, I can only surmise that he did not mean we should provide less than standard care but instead recognized that despite the best care that can be provided, patients can still die.
Responsibilities aside, your post for me highlights the lack of education, support, debrief, training for healthcare professionals (from brand new to old-timers) exposed to dying and death. Although I’m but a layperson (albeit involved in many end of life initiatives) I see the toll it takes on you whose role it is to attend to us – right through to the bitter or bitter sweet end. Thanks for sharing (including wiki visuals!)
Hi Kathy! Although the incident I narrated happened years ago, things have not changed much is my impression. It’s January and new residents have been accepted into training. I do not mentor first year but third year (graduating) residents. I told them about this and reminded them that once, they were first year residents too. We all need to support each other when patients die.
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