MITSS Helps Patients and Clinicians Through Trauma

By Karla A. Knight, RN, MSN
March 28, 2005

Linda Kenney’s ankle surgery on November 19, 1999, wasn’t supposed to be a big deal. After all, it was her 20th surgery to repair the bilateral clubfeet she was born with. She knew what to expect. Her husband was at work planning to pick her up as usual after the surgery, and her kids were at school, expecting to find their mom at home later that day.

Frederick van Pelt, MD, thought he knew what to expect, too. After all, he was an experienced anesthesiologist who had performed nerve block anesthesia many times over. But when he injected the anesthetic into Kenney’s lower leg, her heart stopped.

Three days later, Kenney woke up in the ICU. An endotracheal tube prevented her from asking her husband why he was crying and what had happened to her.

While Kenney was in the hospital, she says no one really told her what happened — an anesthesiologist told her she had a “reaction” to the anesthesia. (According to Kenney, her cardiac arrest was caused by a rare but known complication in which a large amount of the local anesthetic makes its way into the blood stream via an undetectable collapsed blood vessel.)

Although Kenney says she received clear discharge instructions about how to manage her surgical recovery, no one ever offered her or her husband emotional support for the trauma they had been through. Instead they clung to each other and to their relief that she was alive.

Van Pelt was given the afternoon off following the event and says he was told that even the best physicians are sued. He was never allowed to explain or apologize to Kenney while she was in the hospital.

Still, contrary to advice from hospital administration and risk management, van Pelt wrote a letter to Kenney in which he said he hoped she would find healing. Other sentiments he expressed in the letter would later contribute to the development of a group devoted to helping those involved in medically induced trauma — he wrote that he was suffering, too. He believed in honest and open communication and said that if Kenney wanted to contact him, he would be happy to speak with her. At the time, she labeled the letter “damage control.”

Six months later, Kenney was in the throes of an emotional storm, but she decided that she would not pursue a lawsuit. She reasoned that she did not want to ruin someone’s career and says that a lawsuit would have forced her to relive the event over and over.

Taking back the power

“So in April 2000,” says Kenney, “I decided to take the power back.” She rescheduled her ankle surgery and remembering van Pelt’s letter, she attempted to contact him. But she was disappointed to learn that he had left the Boston area (for career reasons unrelated to the event). Kenney felt she had missed her opportunity for closure and healing.

But one week later, van Pelt, having learned that Kenney was trying to reach him, called her. That phone conversation was the beginning of Kenney’s emotional healing. “I knew that forgiving him was a gift to myself,” says Kenney. “I couldn’t be responsible for someone living with the burden of almost killing someone, even though it was unintentional.”

During their conversation, which van Pelt described as the most meaningful dialogue of his life, he and Kenney agreed to get together and meet one another if van Pelt returned to Boston. After the call, Kenney contacted the hospital where the event took place and requested support services. She received no reply. Next, she wrote a letter to the hospital administration saying that it was unacceptable to receive no follow-up to an event like hers — one in which she almost died.

There was no reply from the hospital for two months. Then Kenney says she received legal-sounding “form letters.” She credits the anger she felt about the letters with fueling her quest to find help for people who have endured events like hers.

But Kenney found almost nothing nationally or on the Internet that helped patients in her position. What she found were frequent references to “victims.” She also found that there was too much anger among organizations supposedly devoted to help and support. “There are plenty of people who aren’t angry,” says Kenney. “They are mostly suffering from the emotional impact of the trauma they’ve been through.”

An opportunity for advocacy

Van Pelt and Kenney came face to face when van Pelt returned to the Boston area about two years after the original event. Reflecting on each other’s pain, they asked themselves at that time, “Why aren’t there any support services for everyone involved?”

They answered their own question with the development of Medically Induced Trauma Support Services (MITSS), an organization born out of their mutual concern for the patient’s, family’s, and health care professional’s pain and suffering after a traumatic event in a medical setting.

According to Kenney, patients want several things after a medically induced trauma (defined in sidebar). First, they want the truth about what happened to them. “And,” adds Kenney, “they will know if you’re lying.” Second, they want an apology. Kenney says, “In my case, I wanted someone to acknowledge that this was a serious event.” The third is an assurance that what happened to them will never happen to anyone else. And last, but not least, patients want support. This could come in a number of ways — financial, emotional, whatever they need.

MITSS also recognizes the need for clinician support after adverse medical events. In the initial days following Kenney’s cardiac arrest, van Pelt tried to speak with Kenney’s husband, who asked van Pelt to stay away. Van Pelt came to two conclusions: The husband was unprepared to hear an apology or explanation, and van Pelt was unprepared to cope with this type of situation.

“The mindset at that time was that bad things happen, but you move on. You just don’t get emotionally engaged,” says van Pelt. “I was back doing regional anesthesia the very next day.”

Now, van Pelt feels like he is more in touch with his own humanity as well as that of his patients. “If you use integrity and compassion as your drivers,” he says, “the outcomes can be amazing.”

Support from institutions

James Conway, a self-described supporter of MITSS, says that Boston’s Dana-Farber Cancer Institute, where he is executive VP/chief operating officer, learned from Massachusetts’ Betsy Lehman case 10 years ago, in which the patient received overdoses of chemotherapy and died. Conway and others at Dana-Farber have recognized that there are multiple victims following a traumatic event. “There’s clearly the patient and the patient’s family and friends,” says Conway, “but there’s also the staff members who came to work that day intending to deliver exceptional care and instead find themselves at the ‘sharp end of the error.’”

Dana-Farber also learned that when these events happen, they must be fair and just and not punitive. “The event does not assume one person is responsible when there’s a systemwide responsibility,” he adds.

The message from van Pelt and Kenney resonated with the message Dana-Farber wished to deliver. The hospital has offered financial and logistical resources to MITSS for several reasons, says Conway. “First, they’re good people. Second, they brought an important message that reinforced Dana-Farber’s position on support after adverse events. And last, their vision would bring a degree of depth which was more than the depth we have.”

Dana-Farber’s No.1 responsibility is to the patient, says Conway. The institute offer staff support through an employee assistance program, as well as private counseling. Staff are always included in the evaluation of the event because, Conway says, “we want the discussion to be about what happened, not who’s to blame.” Dana-Farber uses MITSS as a resource on how to view an event and advise on processes.

And Dana-Farber makes sure that staff knows about MITSS. Kenney’s message from MITSS “is not just about incident and harm,” says Conway. “She and Rick [van Pelt] are able to talk about partnerships and the role of family-centered care.”

MITSS and the patient safety movement

The patient safety movement has traditionally focused on prevention of error —standardizing care and eliminating human error as much as possible. “The patient safety movement has not yet focused on taking care of the people involved in adverse medical events,” says van Pelt, “and MITSS completes the loop.”

MITSS is putting together a model for patients and families who experience a medically induced trauma, according to Kenney. The organization is using the experience of several of its support groups to develop the model. When the model is in place, Kenney says that Kaiser-Permanente in California plans to use it in addition to the strong clinician support program already in place.

Conway recognizes that other hospitals might not accept the MITSS vision. First, there is a major issue of confidentiality. “Health care still doesn’t have really good systems to safeguard care and information,” says Conway. Other hospitals may wonder if they can successfully link MITSS with their current support programs. Finally, the concept of the “the other victim of error” [the clinician or staff member] is new territory and has been talked about only in the last five years.

Kenney recently attended the National Academy of Science’s meeting about patient error and says that great things are happening in the patient safety movement. “But it will take years to improve systems to where there is very little or no error,” she says. “In the meantime, patients and clinicians will continue to have emotional backlash.” And helping them all through the trauma will be MITSS.

Karla A. Knight, RN, MSN, is a frequent contributor to Nursing Spectrum.