August FY25

[A Schutter]

Living With the Aftermath: The Second Victim Experience Among Certified Registered Nurse Anesthetists.
This article piqued my interest because very early in my anesthesia career I had a case whereby a 2-day old infant was transported to our hospital for a complete bowel obstruction. Unfortunately, the small outside hospital did not recognize the obstruction and continued to feed the infant. By the time the infant arrived at our institution he was septic, and the prognosis was very grave. The family wanted everything done for the infant, so we transported the infant to the OR for emergency surgery. The infant coded in the hallway on our way to the OR suite and sadly he died before we were even able to move him to the OR table. I remember the events of this day like it was yesterday. After completing all the "paperwork" I went to the Anesthesia lounge to decompress and the Charge CRNA (who was a seasoned much older CRNA) told me to "put on my big girl pants and go finish my list." This incident plagued me for many years and made me question my decision of becoming a CRNA or even remaining in healthcare. Fortunately, not all my colleagues were as insensitive as the Charge CRNA and leaning on them talking about the incident, listening to them tell stories and quite frankly having a good cry helped get me thru this traumatic experience.

My questions for discussion:
Have you ever had a second victim experience as a CRNA? if so what was your experience?
Did you feel supported/How were you supported? What was your coping mechanism?



Here is a link to the article.

[Sue Kim]

Have you ever had a second victim experience as a CRNA? if so what was your experience?
      Yes, during a robotic paraesophageal hernia repair, the surgical team cut a major blood vessel and we had to resuscitate the pt immediately. He ended up making it out of the OR to the ICU that day but over the next couple of days was taken back and forth between the OR and IR until he unfortunately passed a few days later.
      

Did you feel supported/How were you supported? What was your coping mechanism?
      This experience happened several years ago and will probably stay with me forever. I am fortunate that I had a very supportive team of colleagues that was there for me from the beginning. I was able to take a break and decompress a little bit afterwards on the day this incident happened. And during our M and M discussion that occurred a couple of weeks afterwards, everyone was very supportive and constructive throughout the time we discussed this pt and what happened. Even though I was traumatized by the experience, I appreciated that the discourse of the M and M was very helpful and encouraging.

[Ben Waldbaum]

I remember vividly on a Thursday night at 6 PM dropping a patient off at WICU and coming back at 6:15 PM and finding an add on case sitting outside my OR. This alone made me feel unsupported having not been told about an add-on case and to have to start it minutes before leaving. At induction, I told the MDA multiple times not to push a particular medication. Unfortunately, the MDA did not listen and the patient arrested on the spot. We resuscitated the patient and were able to drop off the patient alive in WICU and eventually the patient died. To me, the death was entirely preventable and it really upset me. Years later I still think about it every now and again. I received absolutely no support from the ZBOR call attending that did this late assignment, nor from the MDA on the case, or anyone else. Felt like I was just expected to act like it didn't happen and come back the next day for another day. I think the main coping mechanism for me was time.