Advice for veterinarians: Surgical trauma and the second victim

The metaphorical "cone of shame" applies to veterinary professionals suffering from secondary trauma after medical errors. If you're suffering and distressed after making a mistake during surgery, there are steps you can take to rewire your brain. (Willee Cole / stock.adobe.com)

As a group, veterinarians are trained for quick and confident decision-making in surgery, with little room for error. Profession-wide, we also reside in a culture of shame-or at the very least, we usually don't welcome conversations about our surgical mistakes. Even if we were brave enough to discuss a mistake, it could result in malpractice litigation, loss of a job or damaged self-esteem. We live with the internal conflict of being taught about the uncertainty of surgical outcomes alongside the unacceptability of surgical error.

In veterinary medicine, debriefing or counseling at the individual level after a surgical or medical error is not part of our wider culture. Instead, we hide, try to put on a brave face and try to survive day-to-day, gritting our teeth through adrenal-squeezing surgeries … or just drop out of the profession altogether.

The struggle is real, my friends.

When it comes to surgical errors, there is the obvious victim-the patient-but there is also a second victim, and that is the surgeon. The term “second victim” was coined by Albert Wu, MD, MPH, professor of health policy and management at the Johns Hopkins School of Public Health, in his description of the impact of errors on medical professionals. Bottom line: In situations of medical or surgical error, the veterinarian who makes the mistake needs help too.

Read that last sentence again.

If the concept of helping veterinarians deal with trauma from a surgery gone wrong had existed when I first entered the workforce, then my career (and mental and emotional health) may have looked very different.

Six months out of school I experienced my first surgical trauma while performing a spay on an in-heat, overweight, adult large-breed dog by myself. During surgery I panicked and almost passed out from fear. The dog survived and I got through, but the seed of trauma was planted.

Over the next couple of years, I unknowingly watered that seed by performing more terrifying surgeries without support. I began to experience fear when I was scrubbing, or when I was opening a surgical pack. That morphed into chronic anxiety, and I would feel afraid while I was driving to work, not sure what surgeries were lined up for me.

Pretty soon, by Friday afternoon I was already dreading going back to work on Monday. I was miserable and didn't know who to talk to. I tried talk therapy, alcoholism, praying, berating myself, and so on. Nothing worked.

A couple of years ago, I found this article by Sara C. White, DVM. In it, she lays out the four ingredients that are necessary to cope after surgical trauma: technical learning, perspective, emotional learning and support. Whether you engage in those things or not predicts whether you will survive, thrive or stop performing future surgeries altogether.

It made a lot of sense. She demonstrated how veterinarians tended to do better if they sought support from colleagues, learned from their mistake, and maintained the proper perspective that no one is perfect (that's why it's called practice!).

The thing that stood out to me the most was the concept of emotional learning. I realized all the “strategies” I was using were actually making things worse. It wasn't that I was a bad veterinarian, it was that I lacked the tools and awareness needed to change patterns that had been established by trauma.

Are you ready for the secret? In essence, desensitizing and counter-conditioning a dog to overcome fear isn't much different than doing the same for a human. We just tend to be much nicer to fearful dogs than to ourselves.

The steps I learned to rewire my traumatized brain into something healthier went like this.

1. Identify the physiological and thought patterns that occur when you are anxious about surgery, and write them down

What happens in your mind and body when you get triggered by something that scared you in surgery? For me, my heart would start racing, I would feel nauseated, my hands would shake, I would get really snappy, I would breathe more shallowly, etc. Thoughts like, “I hate surgery!” or “I am not a good surgeon!” would swirl, and I would obsessively mull over my surgery schedule all morning.

Not. Helpful.

Imagine, instead of watching a dog for signs of fear, you are watching yourself. Identifying and knowing what happens when you get triggered will help you understand your own fear biology.

2. Identify your triggers, and write them down

Once you have identified your physiological and emotional signs of fear and anxiety, it is time to identify the cues in your environment that are causing your sympathetic system to go haywire. Is it when something goes wrong in surgery? Is it when you are scrubbing? Is it the night before? Knowing your triggers will help you understand when your amygdala has been thrown into fight, flight, or freeze.

3. Baby steps: Work below your threshold

If you have been scared by surgery, then you need to work beneath your fear threshold. Yes, I know that presents certain challenges, but if you don't, you may never heal. Start small with procedures that don't scare you-mass removals, dental extractions, neuters. Maybe it is just being in the surgery room without panicking. Enlist a calm companion. If you do well and don't get triggered (remember your signs!) then move onto something bigger. If you get triggered, step it back to something smaller, and be kind to yourself. It's just like slowly moving the reactive dog closer to a bike while working beneath that dog's reactivity threshold. Write down three surgical baby steps you can take in your journal.

4. Reward yourself consistently

If you take your baby steps successfully, then reward yourself! It doesn't have to be something big. It can be a movie night, or a Starbucks drink, or a walk by yourself after work. Just like you give the dog treats for not losing it over a bike, you need to give yourself treats to create new neural pathways. Write down three rewards that you will give yourself next to your baby steps and then be consistent in doling out those rewards.

5. Be patient and praise yourself

This might sound weird, but beating yourself up after a surgical mistake actually makes the whole situation worse, and reinforces the trauma patterns in your brain. You have been through something hard; be patient with yourself and develop a habit of positive self-talk that will buoy you through difficult procedures.

6. Breathwork is a super power

Did you know you can actually calm your nervous system down with the power of breathwork? It's true! If you find yourself ramping up in fear, try utilizing coherence breathing or box breathing. Both techniques shut down the sympathetic system and activate the parasympathetic system, something you will need if you are going to keep your head in surgery.

7. Utilize pharmacology and experts when needed

Just like in dogs, sometimes you need a little something extra to raise the reactivity threshold. Don't be ashamed to talk to a therapist and ask for pharmacological assistance if you need it. I went through 20 sessions of neurofeedback and talk therapy. It's not a sign of weakness, it is a sign of strength, awareness and much needed self-love to seek help when you need it.

Remember, the second victim is real. Don't minimize or negate the presence of trauma and fear in vet practice-arm yourself to do something to change the outcome. And remember you can always, always, ask for help.

Dr. Sarah Wooten graduated from UC Davis School of Veterinary Medicine in 2002. A member of the American Society of Veterinary Journalists, Dr. Wooten divides her professional time between small animal practice in Greeley, Colorado, public speaking on associate issues, leadership, and client communication, and writing. She enjoys camping with her family, skiing, SCUBA, and participating in triathlons.