I was asked to write an article about second victim syndrome (SVS) as it was suggested that I may be an expert in the area. Let me state up front, I do not self-proclaim to be an expert in the area of SVS. I can say I’ve been a practicing anesthesiologist for 20+ years and during that time I am certain that I have experienced SVS on numerous occasions. Furthermore, on October 1, 2017, I was thrust into duty running point for an operating room caring for over 200 victims of the Las Vegas Mass Casualty Event1 arriving at our trauma center Emergency Department over several hours. In processing this experience and in sharing the lessons learned from it, I came to understand that many patient-related adverse events are not over when the event ends. Therein lies my academic introduction to SVS. The multiple lectures that my husband (Nicholas Fiore Jr., MD, a pediatric surgeon) and I have given on our experience were incomplete without a discussion on SVS. The imprint this event left on me is indelible and every time I tell my story, the anxiety it produces gives way to a sense of healing after an emotional and psychological wrestling match.
The term second victim syndrome was coined by Albert Wu in 2000 and refined by Scott et al. in 20092 to describe the state of mind of a health care provider whose patient has experienced an unanticipated adverse event, medical error, or care-related injury as the “first victim.” Second victims are health care providers who are involved in an unanticipated adverse patient event, in a medical error and/or patient-related injury, and are traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed their patient and start to second guess their clinical skills and knowledge base. The term SVS has become internationally recognized by health care providers and managers as well as policy makers because it is memorable and invokes a sense of urgency. Simply put, the psychological trauma that follows a stressful event often with negative outcomes creates a second victim, the health care provider. Studies have shown that nearly 80% of health care providers experience and are psychologically impacted by a significant adverse event at least once in their career.3 It is estimated that patient safety incidents (PSIs) occur in one out of seven hospitalized patients.4 System failures occurring before a health care provider even enters the picture can lead to medical errors and unforeseen outcomes. Since PSIs can range from mostly near misses up to permanent harm or death, hospital systems increasingly realize their role in providing an institutional support system. Whether it be systemic error or provider-related, we feel liable for the outcome. A health care provider involved in a PSI has an increased chance of developing post-traumatic stress disorder (PTSD).4
What do we know about the SVS? First, we must accept that it is extremely common. The prevalence is estimated to be 10.4–43.3% of providers following a traumatic experience.5 Each of us will express our own reaction. These reactions can be emotional, cognitive, and behavioral. Our coping strategies can impact our patients, other providers, and our families, as well as ourselves. Some providers may feel not worthy of being labeled a second victim. The night of October 1st, one of our PICU nurses felt she had made no contribution to the care of our over 200 patients. She was stationed at one of the double doors from the ED to the OR and spent her time repeatedly hitting the door plate which opened the door allowing caregivers to pass back and forth. I told her I personally ran back and forth down that hallway over one hundred times to care for patients and I never waited for the doors because she was there. She experienced emotional trauma that evening as we all did.
How do we cope with SVS? Our mental health and how we respond to emotional stress is a unique part of each of us. We process, understand, cope, and come out the other side after a traumatic experience at our own pace. If we are not able to recognize the signs of SVS and learn how to cope we may end up developing physical symptoms including chest pain, headaches, poor concentration, hypervigilance, or sweating, to name a few.6 Coping mechanisms to help rebuild or maintain personal physical strength and health include the following:
- Returning to daily activities which includes exercise, reading, socializing, journaling, or findings one’s personal best.
- Interacting with family members who can provide comfort.
- Learning to process emotions and understand the experience.
- Finding and receiving help from friends and colleagues.
- Most importantly, knowing when to seek professional help.
Signals that you may need to seek out professional help from SVS may come from experiencing dreams and thoughts that evoke painful emotions and interfere with daily life. Others may notice dramatic changes in their behavior and try to assist you. If you experience thoughts of hurting yourself, seeking professional assistance and guidance through the healing process is a must. Your ability to cope may be influenced by your current personal circumstances, past experiences, and your core values and beliefs. Strength of relationships with loved ones and, of course, one’s personal self-care and self-love are vital.
Intervention can help guide you through your experience and help you in processing your emotions.
As important as coping is resiliency. Through time and with maturity, one learns to bend without breaking. This requires acquisition of the tools to withstand the traumatic event and learn to recover quickly from difficult situations. Realizing the importance of a strong support network will help combat common reactions. We may experience mental and physical exhaustion, and may feel dazed, numb, sad, helpless, and anxious. These feelings can spiral downward, with the second victim replaying and reliving the experience over and over. Without intervention, long-term sequelae may evolve into PTSD, depression, suicidal thoughts, and/or alcohol or drug abuse.
I believe that we all have multiple SVS-producing experiences during our careers, some more powerful than others. Any time we feel responsible for an unexpected outcome, adverse event, or clinical error, it affects us. How can it not? The compassion and desire to help someone is at the very core of health care providers and makes us vulnerable to becoming the second victim. For example, when a partner calls you to recount a stressful patient experience resulting in an undesired outcome, whether or not patient harm ensues, aren’t they simply expressing their feelings as a second victim? When something negative happens, as simple as missing an IV or more serious such as missing a STEMI, we first judge ourselves and feel responsible. You may have been in a situation where you “did all you could” and the outcome was not as favorable as you hoped. If this experience is not processed by our personal protective mechanisms in time, we may begin experiencing doubt, anxiety, depression, anxiousness, or even denial and fear of repeating the same mistake. Whether the patient’s course culminates into a prolonged hospital stay or in a malpractice proceeding, we struggle to carry on. A basketball shooting guard on a cold streak may keep asking for the ball, believing his next shot will always go in. We often don’t respond the same way. Instead, we wonder if everyone knows what happened. We ask will it pass and will our reputation be irreversibly affected? How can all this not lead towards the dreaded burnout syndrome? We are taught early in medicine to compartmentalize our feelings. Move on. Accept the outcome. Learn from it and do not repeat it. Don’t let it get into your head. Family and friends may see this behavior as seemingly harsh, unsympathetic, or stoic when it involves personal family members.
Many have contributed to our understanding and treatment of SVS. Among those is Kathy Platoni, PsyD, who specializes in the treatment of PTSD and war trauma.7 Throughout her career as a U.S. Army Psychologist, in both active and Army reserve status, she developed programs addressing combat stress control, and emphasized the importance of debriefings and crisis management. As a survivor of the Fort Hood Massacre herself she learned from personal experience and her well-known quote “Trauma is so very unforgettable” is often referenced.7 She is an outspoken advocate declaring that a mass shooting is an act of terrorism.
Barbara Van Dahlen, another leader in the field of SVS, created giveanhour in 2005 to provide free mental health care to active duty, National Guard and Reserve service members. Their mission is to develop national networks of volunteers capable of assisting those that have experienced acute and chronic traumatic stress-related conditions that arise in our society. More recently giveanhour has partnered with #FirstRespondersFirst to offer mental health services during the COVID-19 pandemic. Their activities highlighted that SVS is not always directly related to a violent event. For example, a planned difficult airway where you call for assistance that evolves into a prolonged difficult intubation may leave you questioning your skills, decisions, the situation, and possibly yourself. While writing this review, I had a resident miss two IV attempts on an 18-month-old. After the case, she expressed how horrible she felt about the situation and that she hurt the baby. She expressed her concerns that she wasn’t good enough to pursue pediatric anesthesia. We sat and we talked, a debrief of sorts, and went through the difficulties and successes of our day. I assured her with time, training, and dedication she would overcome this one obstacle.
The stages to recovery from SVS are well-described, not unlike the Kubler-Ross stages of response to death or loss.8 Initially, the second victim has feelings of chaos and accident response, an initial loss of control provoked by the event. Ideally, the negative effect of the adverse event is limited by colleagues who help provide ongoing care and prevent additional harm. The second victim then replays the event in their mind and may have difficulty focusing or concentrating due to intrusive reflections. Again, peers play a vital support role as the victim works to restore personal integrity. This is not the end, however, as the inquisition and investigation ensues, possibly culminating in litigation. As one endures this stage, it’s important to receive emotional first aid and seek peer or professional support. Finally, the second victim is hopefully able to move on and recover. Some practitioners, unfortunately, limit their practice and even leave clinical practice as a result of their traumatic experience.
On the first anniversary of the October 1st Las Vegas Mass Casualty Event, our hospital set up a lunchtime memorial for survivors and caregivers alike, an anniversary wake of sorts, to provide comfort for each other and search for meaning in the unspeakable terror we experienced together. Such an event is a circle that never closes, a story without an ending– but we were united by the understanding that we, and life, must go on. We cried till we laughed. We told stories and took pictures, celebrated life and life lost. And in the end, we all walked out the door of the meeting hall, together, tattooed with that experience and the belief that we would go on.
We as anesthesia professionals carry a substantial daily burden. Patient needs, practice demands, family requirements, and “satisfaction scores” from both our patients and the hospital system continually weigh on us. In today’s immediate world, with instantaneous access to information from the internet, there is no tolerance for a poor outcome. Patients often arrive with their own WebMD diagnosis, treatment plan, and prognosis that they expect to play out without a hitch. This places our clinical practice under an increasing amount of scrutiny. In other professions mistakes are more readily accepted and at times even expected. How often do we take our vehicle in for service only to have to return back to the garage within a week when the ‘service light’ comes back on? We accept this, we tell ourselves this was not an unexpected outcome, and we just deal with it. In medicine “the light” coming back on is unquestionably unacceptable. The demands and expectations that are placed on us hourly, daily, monthly, can lead to burnout. Burnout is higher in health care than any other industry. Our personal expectations continue to push us daily. But how far? When do our safety and our patient’s safety become jeopardized? Managing the SVS, in ourselves and others, is an important component of professionalism. We should recognize the cause and teach ourselves how to mitigate the effects.
- Woods A. “Is this real?’: Seven hours of chaos, bravery at Las Vegas hospital after mass shooting”. The Arizona Republic. November 11, 2017.
- Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider ‘second victim’ after adverse patients events. Qual Saf Health Care. 2009 5:325–530.
- Vanhaecht, K, Sevs, D, Schouten L, et al. Duration of second victim symptoms in the aftermath of patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands. BMJ Open. 2019,9:e029923.
- Wu, AW, Shapiro, J, Harrison R, et al. The impact of adverse events on clinicians: what’s in a name? J Patient Saf. 2020 16:65–72.
- Seys D, Wu AW, Van Gerven E, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013:36:135–162.
- Karydes, H. Second Victim Syndrome: a doctor’s hidden struggle. Physician, May, 2019.
- Platoni, K. Personal bio. Google. 2021. www.drplatoni.com Accessed May 19, 2021.
- Scott, S. The second victim phenomenon: a harsh reality of heath care professions. https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions. Accessed May19,2021.