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The 'second victims' of medical tragedies

No one thought the baby would die. Though the heartbeat inside his mother's womb was faint, doctors at the Central Massachusetts hospital were sure they could save the child with an emergency caesarean section. Then his heart stopped moments after birth and no amount of drugs could revive him, leaving the mother and everyone else in the operating room grief-stricken.

"I came pretty close to quitting my job," said one veteran nurse. "I came very close to losing it psychologically."

But hospital administrators were wary about her speaking to an outside psychologist, fearing he could be called to testify in a malpractice lawsuit. "The hospital is more worried about lawsuits than they are about the effects the incident has on the staff," said the nurse, who asked that her name not be used and her hospital not identified. "Unfortunately, that's where you get left."

Now, doctors, nurses and patients are taking the problem into their own hands.

An organization founded by an anesthesiologist and his patient, who nearly died during routine surgery, is offering group counseling for nurses who have witnessed -- or even caused -- unexpected injuries to patients. If doctors come forward, Medically Induced Trauma Support Services will offer group sessions for them, too.

The Mansfield-based group is in the vanguard of a movement that views doctors and nurses as the "second victims" of medical tragedies, often psychologically damaged by the harm done to their patients and eager to make amends when it's their fault. In a nation where up to 2 percent of patients are injured by care givers while in the hospital, the trauma support group believes that tens of thousands of health professionals experience on-the-job traumas that they never fully discuss.

"You keep putting all that stress on people and pushing it down. Where's it going to go? That's a scary thought," said Linda Kenney, 42, who cofounded the group when she couldn't find a forum to discuss her near-death experience at Brigham and Women's Hospital five years ago. Firefighters and other emergency service providers have had this kind of crisis counseling for years.

Kenney's collaborator, Dr. Rick van Pelt, also discovered little support in the aftermath of surgery in which the anesthesia he had intended for her lower leg escaped to her heart, sending her into seizure and then cardiac arrest. Surgeons had to crack open her ribs to perform the open-heart massage that saved her life.

Van Pelt wanted to apologize, but he faced a series of obstacles including the raw anger of Kenney's husband, the medical team that urged him to stay away, and the anesthesiology chief who made it clear lawyers should handle the case. Van Pelt settled for a letter to Kenney saying he was "deeply saddened" at her suffering.

"The system operates in the belief that when an adverse event happens, it's best for a physician to distance himself," said van Pelt, whose job at the Brigham now includes patient-safety concerns. "It's so ingrained in physician culture. What followed was me being shut out."

Both the Brigham and Dana-Farber Cancer Institute have officially urged doctors to disclose mistakes to their patients since 2001 -- which the national group that accredits health-care institutions now urges for all hospitals -- and, so far, neither hospital has been sued as a result of admitting mistakes.

But Kenney's anesthesia accident "occurred at a time where we in the medical profession were in transition from a culture that was trying to shield itself from vulnerability to litigation," said Dr. Anthony Whittemore, chief medical officer at the Brigham. "We have begun a transition that has sought vigorously to reverse that culture to establish a so-called blame-free environment . . . in a way that would not have left Rick vulnerable."

Kenney initially considered a lawsuit, but dropped it after van Pelt's repeated attempts to apologize to her, saying in an interview that "Rick went above and beyond what he had to do."

A recent study by the Meyers Primary Care Institute at the University of Massachusetts Medical School showed survey respondents were almost 40 percent less likely to seek legal advice over any kind of medical mishap if the physician acknowledged it and apologized. The study found that patients were nearly as likely to seek a lawyer over life-threatening mishaps, whether the doctor admitted an error or not. Patients who actually sued, however, usually said they felt their doctor had not fully disclosed what had happened.

In 2000, Dr. Albert Wu, a professor at the School of Hygiene and Public Health at Johns Hopkins University in Baltimore, sharply challenged the silence and stoicism surrounding mistakes with his influential British Medical Journal essay, "Medical Error: The Second Victim," in which he described how shattering medical mistakes can be to the people who make them:

"Virtually every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed -- seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient's anger."

Doctors who reviewed Linda Kenney's ankle-replacement surgery couldn't find any lapse in van Pelt's administration of anesthesia. In hindsight, van Pelt suspects the anesthesia escaped through a collapsed blood vessel, so no blood backed up in a test syringe to warn him. But such details didn't help Kenney or Kenney's husband, Kevin, who had left his wife at the hospital for the operation and returned to find her fighting for her life.

Van Pelt said he was never punished or literally forbidden from speaking to Kenney, but he found little support either for contacting her or processing his own feelings about the disaster. "I was in OR the next day," he recalled. "The message was, 'Get back on your horse,' because you always get back on your horse."

By the time Kenney felt ready to respond to van Pelt's letter of apology, six months after the operation, he had left to work at a start-up company in Seattle. Though the move was unrelated to Kenney's near-death specifically, van Pelt acknowledged that the incident motivated him to pursue other interests. Kenney initially called van Pelt to tell him she forgave him and, in November 2001, they finally met in her hometown of Mansfield.

So far, the trauma support group has provided support for about 50 patients who called its hot line and is only now beginning to offer counseling for care providers. The group is struggling to draw doctors who have experienced medical tragedy, but Kenney is encouraged that hospitals increasingly support their effort; about 100 health-care professionals attended the support group's annual dinner this year compared to none in 2003.

For the nurse who watched the baby die at a Central Massachusetts teaching hospital last winter, the trauma support group is a godsend. Although she eventually got counseling through a trauma program designed for firefighters, she is eager to share her hard-won recovery story with other nurses who are suffering from posttraumatic stress. Ultimately, she wants to be one of the counselors.

"I'm an extremely strong person," the nurse said. "It scared me when I realized how close I had come to leaving nursing completely."

Scott Allen can be reached by email at allen@globe.com.

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