Inside the Whirlwind

Last spring, I wrote a pair of blog posts introducing the notion of the “second victim.” In the first, entitled “Albert Wu and Me,” I offered a taste of my personal experience with a patient’s heart-breaking outcome, elaborating on the impact that the words of Dr. Albert Wu had on me in that very dark hour. In the second, called “Living Among Heroes,” I began an exploration of a very important concept — the second victim phenomenon — and promised to dive in further someday.

Well, guess what? Someday has come!

Today, I want to explore the feelings of the second victim a bit more in depth. Before I do, though, I want to lay a little groundwork.

Not uncommonly, people use the term “second victim” to refer to a healer who is experiencing what some call “compassion fatigue” or “secondary trauma.” These notions are not interchangeable with that of becoming a second victim, however.

Not all who experience compassion fatigue become second victims. And there are surely second victims who were not “compassion fatigued” before being hit with a second-victim whirlwind.

I often hammer this point home when I speak on this topic for a very specific reason. While it may feel academic, the difference actually matters, especially to those in the midst of litigation. It matters because the nature of these two experiences and the healing processes they require differ.

To ensure that we’re talking “apples and apples,” let’s begin by clarifying exactly who the second victim really is.

Inside the Whirlwind of a Doctor with an Adverse Outcome

Who Is the Second Victim?

The term “second victim” applies to humans with a very particular sort of life experience.

As pilot Sidney Dekker and other experts have defined it, the second victim is a person who is involved in an incident that injures or nearly injures someone else, for which that first individual feels personally responsible. When harm comes to a person the professional in question was intending to protect -- and especially if they believe they may have had a hand in the harm themselves -- they themselves are injured in a way they may never have been before.

Key insight:

All second victims tend to have two things in common:

  1. A deep, personal commitment to the welfare of others; and

  2. Work where safety is generally critical, characterized by high levels of complexity, frequently involving rapid-fire decision making in the face of limited knowledge and significant unknowns.

How Does It Feel When Your Patient Has an Adverse Outcome?

People work under these circumstances in many domains — healthcare is just one. Nonetheless, this combination really captures the work we do, doesn’t it?

Many of us are deeply committed to the welfare of others. Why would we pursue all the education we have unless we were?

Dr. Rachel Naomi Remen expresses it beautifully when she writes,

How many times are our actions … motivated by love without our ever knowing it, even when our love is profound and part of who we essentially are? It is easy to recognize romantic love, parental love, fraternal love, the love of country and the love of friends. But how about those of us who love with our minds, studying for years in order to be there with the knowledge to help strangers or those of us who persevere despite daily difficulties because of a deep love of life?

And as for the second point, apart from any complexity implied by the diverse work environments we inhabit in healthcare, won’t the human body always bring us high complexity and significant unknowns? No matter how far our scientific understanding progresses, I can’t imagine we will ever fully comprehend the mysterious inner workings of the biological organism that we are.

So, how does the Whirlwind feel?

How does it feel to become a second victim? As with other complex life events — bereavement, childbirth, a challenging injury — each person’s experience is nearly as unique as the individual themselves. Nonetheless, research has unearthed general trends.

Most second victims describe a mix of intense emotions and physiologic sensations. Grief, shame, and guilt are major contenders, but they are not alone. Second victims often find themselves immersed in fear and overcome at times with anger.

Emotions of the Second Victim

Not uncommonly, second victims find themselves plagued with intrusive thoughts and self-doubt. Distraction, exhaustion, and feeling stunned are commonplace.

Beating Ourselves Up

Perhaps unsurprisingly, we physicians, prone to perfectionism as we are, tend to engage in self-criticism when the second victim firestorm comes to call on us.

First, some of us beat ourselves up for the patient’s outcome and what we perceive as our role or possible role in it. Second, we often find ways to beat ourselves up for the overwhelmed feeling the experience gives us. After all, aren’t we taught that we ought to be able to divorce ourselves emotionally from the sad things which happen to our patients?

Learning to manage this onslaught of emotion is one of the most challenging things I think many of us will ever do. For those who are struggling in this domain, this becomes one of the prime foci of the coaching work I do.

In future posts, I plan to dive a little more deeply into some of the specific feelings of the second victim. Each one has a place and a meaning. Once we grasp what the feelings mean, we are better equipped to contemplate what we might do with them when they happen to us and how we might be of support when they happen to others.

Join me next time and we’ll begin that important journey. And if you should find yourself in need of one-on-one support, I invite you to reach out to me here.