Enduring the Injuries of Second Victim Syndrome

Originally published by our sister publication General Surgery News

Dear Colleagues:

I am a 30-year veteran general surgeon. I just turned 60. Two days after one of my happiest days celebrating my milestone birthday, I lost a patient following a laparoscopic cholecystectomy—an elective one, at that. Granted, this was a complicated patient with a complicated abdomen and a very sick gallbladder, although he was asymptomatic. His scans were overlooked for over three years when I advised him to consider the procedure to stave off possible complications that could occur if he were to wait until becoming symptomatic. I do believe I provided him a balanced recommendation and even had the approval of his long acquainted primary care physician. The patient and I both understood the risks.

His cholecystectomy was incredibly difficult due to chronic scarring and massive abdominal adhesive disease. I was making slow but steady progress doing a dome-down technique when I hit a liver bleeder that was unlike any I had ever seen. I knew immediately that I had a significant challenge. I remained calm and controlled the bleeding by pushing the gallbladder against it laparoscopically. Eventually, I opened the patient to control the bleeding and left him packed with an open incision postoperatively. Approximately five hours after beginning the procedure, I had the bleeding controlled. I had consumed the entire hospital supply of hemostatic agents and had given the patient blood products, tranexamic acid and had four people assisting me. I never let the patient bleed significantly, but was never quite able to find the source well enough to tie it off. (The point of this composition is not one of surgical technique—after 30 years and countless lap choles, I believe I know technique.) Fourteen hours following the start of the procedure, the patient died in the ICU. He had a terrible acidosis that was never overcome—again, this composition is not about the operation.

I had just attended a lecture series on “The Surgeon as Second Victim” at the American College of Surgeons Clinical Congress in San Diego. While I appreciated the subject and the speakers, it had been quite some time since I had lost a patient perioperatively. But here I was, just days after attending the lecture. Now I was the second victim, again. In 30 years, it wasn’t my first time losing a patient, but it was my first time fighting over a bleeder from a lap chole for hours before losing the patient unexpectedly. Those hours spent fighting for my patient’s life were like nothing I had ever felt in my long career. The sustained adrenaline I dealt with that afternoon made me shake at times. It made me pray out loud to God above. I asked my team to pray; I even asked the family to pray. I was scared. I stayed with the patient until all I could do was done. Letting the intensive care provider take over postoperatively was painfully difficult, but I was exhausted. Everyone told me I did a great job, but I felt absolutely defeated inside.

I went home very late that evening. I had done 12 endoscopies and a lap chole from hell. I lay in bed that night praying Psalm 23 over and over again. I said the Lord’s Prayer over and over again. I drifted to sleep somehow, but was awoken by my phone with a text from the ICU provider informing me my patient had expired. It was 3 a.m.—so much for any more sleep. I lay in bed wrestling with everything mentally from, “Did I do a good enough job?” to “Should I go in right now and meet with family?” to “Should I retire?” The next morning, I went to the hospital and sat stunned in my study. I told my partner I didn’t think I was up to doing any cases and asked if he would cover some of mine. Some cases were simply canceled and patients were informed I was ill. My partner did a few endoscopies for me. My administrator and clinic manager checked in with me personally to ask how I was doing and expressed their care and appreciation. My chief of staff checked in. I called the family of the patient and expressed my condolences and answered some questions. I offered to meet with them at their request in the future. I went home early. Two days later, as planned, I took a marvelous trip with my wife to the Pacific Coast. We spent four nights away from everything, and when I came back, I at least had some new memories to help separate me from what had happened. But honestly, the work was just beginning. I told my wife, a registered nurse, that I felt physically ill from the whole thing. It wasn’t just that the patient had died postoperatively, but that I had been so emotionally and physically shocked by the many hours of sustained effort and ultimate failure that I was in a state never before felt. I explained to her that the physical experience of the operation was so long and complicated, that I had physical as well as emotional injury.

In case you’re wondering, it took nearly 3.5 hours to get the bleeding stopped enough to put the patient into the ICU with packing in the abdomen. The total blood loss was an estimated 1,500 mL. Not the worst I’ve ever seen, but the patient did very poorly on the operating table, and blood pressures were terribly low in spite of my sustained efforts to never let him bleed more than 25 to 50 mL at a time. Of course, part of my recovery is trying to quiet my ego. There is a part of my mind that makes me question the anesthesia provider and their abilities. That is an entirely different matter altogether, but it is tied to my recovery.

I am writing this 19 days since the event. As of yesterday, I told my son, “I feel depressed.” I’ve never suffered with depression in my entire life. I have had sadness, stress, anxiety and grief, but never a sustained depression. This time feels different. I am tired, I am irritable, I am not sleeping well, I have lost weight, my bowels are all over the place and I’m scared of doing a lap chole again. Have you ever had this happen in your career?

I have a therapist, adult children, an RN wife and great colleagues and nurses. Everyone has pitched in to my recovery. I have shared my feelings and my current condition with them (for better or for worse). Everyone seems to understand and respect my recovery period. One of my nurses asked me if I would consider taking medication for my emotional state—it is an interesting question. I have never taken antidepressants or other mood-related medications. I have taken six or seven alprazolam tablets in the last four years to manage mild to moderate anxiety. Generally, I exercise regularly, eat well, play the piano and love it, have a wonderful home and loving pets, live in a great location, and enjoy a happy disposition. But this is new. I am in uncharted waters. I believe it was the sustained agony of the operation and postoperative events that have affected me in a new way. Maybe it is also my age and my overall realization of my own mortality and human limitations. Whatever it is, I am committed to recovering. I do realize that my future patients need me to be at my best—they expect it.

Thus far, I am not eager to use medication. Fortunately, I have a fairly straightforward schedule the next few weeks. No great big cases, just many short procedures. But I recognize that any complications will trigger a post-traumatic stress disorder type of response right now. It will be important to rest and focus on recovery. I am trying to stay engaged with as many things as I can that I enjoy. Simple things like organizing my clothing closet, caring for my aquarium, practicing the piano, doing dishes, folding laundry, walking the dog, etc. All these things that are part of my life seem to be small bites of support each minute, each hour. We general surgeons do dangerous work. We are good at it, but sometimes shit happens. How do we deal with that? For me, it seems like allowing the feelings to be felt, the thoughts to run their course and to communicate with others are elements that aid the process of healing. I may never be the same, but I can accept that. I have to. Now, back to my life.

Dr. Dachman is a board-certified general surgeon with over 30 years of clinical surgical experience, practicing in Watertown, Wis. He is a robotically trained rural general surgeon, part of a multispecialty regional medical center. He can be reached at adam.dachman@watertownregional.com.