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 He was withdrawn and silent at rounds.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