Pause. Process. Proceed.

By McKenzie Warshel, DO, Kirlos Haroun, MD, & Neda Gould, PhD, Johns Hopkins Medicine 

This is a story that a close colleague entrusted me with—one that he’s carried for years, and that he gave me permission to share. It was his first day as an emergency medicine attending, already overwhelmed with a busy morning of sick patients. A 45-year-old woman with end-stage renal disease from FSGS, diabetes, hypertension, and severe vascular disease came in with what seemed like a relatively benign concern: a displaced trach. She was stable, breathing comfortably, and even joking a bit with her mother at the bedside. Her trach size was unusual, so they called respiratory therapy and ordered a chest X-ray to be thorough.  

Her mother turned to my colleague and said, “My daughter hates hospitals. Can we just fix this and go home?”
 

He reassured her, “Of course. We’ll get this taken care of and get her home soon.” 

But as they waited, the patient began to feel mildly short of breath. A bedside cardiac ultrasound unexpectedly revealed a pericardial effusion. She wasn’t hypotensive, wasn’t in distress, and had no chest pain—just this subtle, unexpected finding. The cardiology team was consulted, agreed she needed to be admitted, but didn’t feel an urgent tap was necessary. The trach was replaced, and she asked again to go home.  

My colleague gently told her, “We need to admit you. We don’t know where this fluid is coming from.”  

She was frustrated but agreed. An hour later, she rapidly decompensated into tamponade. My colleague, still unfamiliar with this new emergency department, couldn’t immediately find the equipment needed for pericardiocentesis. CPR was initiated. It took 30 minutes to locate the kit. After 45 minutes, they drained 200 cc of fluid—but never regained a pulse. 

Years later, he still wonders: “Should I have pushed harder? Should I have had the needle ready? Did I do right by that patient?” And perhaps most painfully, “Did I keep my promise to her mother?” And on that day, he just had to keep going—finishing the shift in a daze, doing his best to care for every patient that followed. 

As healthcare professionals we expect perfection from ourselves, and our patients may expect it too. We sometimes forget that we’re human. Mistakes, bad outcomes, and missed diagnoses will happen. These events affect us whether we want them to or not.  

Second victim syndrome 

Second victim syndrome is the emotional and physical burden healthcare professionals experience after a clinical encounter where the patient is the first victim, and the clinicians is the second. Processing traumatic events takes time. However, as the burdens on healthcare professionals increase, we have less time to acknowledge and process challenging feelings in the moment.  

We developed the ALL-CLEAR acronym as a brief tool that can be utilized on a clinical shift to bring your whole self to the next patient encounter or situation. This tool can be put in clinical practice even when just walking from one room to the next, which may be all the time we have until we can think more deeply about the experience later. 

ALL-CLEAR  

A: Accept that the challenging event occurred.

This doesn’t mean we like it or resign ourselves to it, but that the situation did happen. 

L: Label the emotions you’re experiencing (sadness, anger, frustration, anxiety, etc.) 

L: Learn from it.

If there’s something you can learn quickly, great. If not, you can come back and reflect later.  

— This is a Space for a deep breath or mindful moment.

This can be tailored to the amount of time that you have. Even five seconds will be helpful. 

CLEAR: Clear your mind from the previous event and move on to handle the next situation with your whole self.  

Click on these links to learn more about McKenzie Warshel, DO, Kirlos Haroun, MD, & Neda Gould, PhD

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.