As tragic events unfolded in downtown Hamilton December 2, 2017 a young hero was shot in the abdomen while coming to the aid of an individual involved in an altercation. Over the following days partial accounts of witnesses have been published questioning the actions of the paramedics that responded and making statements about comments made on the scene. As a result social media commentary has ensued with a wide and varied reaction from the public and professionals alike.
First, let me say that the family of the victim AND the Paramedics deserve our empathy, sympathy, caring, and support. There is nothing that will change this outcome now. Finding justice lies with the perpetrator of this cowardly crime. The questions raised about the paramedics actions are fair and reasonable. None of us were there. Those that were there have an account of the incident and the best therapy for them is to get their account out into the open. They too are suffering.
In the past couple years Hamilton Paramedic Service (HPS) has been industry leaders in implementing a Just Culture approach to a “collaborative culture of safety”.
In this approach there are avenues for systemic failures, gaps in guidelines or processes, personal performance issues, human error and at-risk decision making. These are the pathways presented by Paul LeSage in the Collaborative Culture of Safety program. There is room for retributive justice, but those are few, when a full account and proper analysis is applied.
The circumstances described in this case will challenge and test all of the hard work the leadership of HPS to apply the aspects of this approach to an investigation into the accounts brought to their attention. Trust needs to be placed in these leaders to follow their just culture approach to potentially adverse events. I have had the honour of working with many of the HPS’ excellent paramedics and leaders. They are professional, trustworthy and have done immense work on developing this culture.
What I will discuss on this topic is an aspect of just culture known as second victims presented by Dr. Sidney Dekker in his teachings on Just Culture and Human Factors. In addition I will look at elements that are part of the just culture approach to dealing with situations such as these.
Most importantly: A key premise of Sidney Dekker is his statement that, “A just culture accepts nobody’s account as “true” or “right” and others wrong.”
Every person who was witness to this incident has an account. Their accounts is affected by many different aspects. Are they visually impaired? Are they hearing impaired? What angle did they observe? Did they see the incident from the front, back, side? How close were they when they overheard comments? What is their past experience with Paramedics? Do they have medical knowledge? What are their childhood experiences?
Every person has ingrained bias’ based on their knowledge and experiences that lead to a varied perspective. No person can see the same incident, event or conversation through the same lens as another. It is absolutely impossible. Thus, Dekker says that no account is true or right while another is wrong. They are all right. And all accounts must be heard.
Many times this is be most significant issue when victims or family members pursue litigation. They were not given the ability to be heard in the investigation process. They want the organization to hear all accounts to know what happened, they want to tell their account and have their hurt understood. Without this opportunity to share accounts, those investigating do not get all of the information and those involved do not get closure if they can’t share their account.
Often when there is a path of retributive justice the legal system destroys the opportunity for closure by those “family or witness second victims” by taking their accounts out of context and abbreviating them with legal arguments. The judge or jury often does not hear a true and full account of victims or witnesses. They never end up feeling closure despite being afforded a damages award.
In medicine it is our responsibility to hear the full accounts and collect the facts through as unbiased a lens as possible. Understanding your own bias’ is the first step. We all have them.
In my previous article Just Culture: The Problem with Retributive Justice I discuss the basis of a just culture and the difference between restorative justice and retributive justice.
What do the victims and their families really want? The families of victims in many cases are extremely kind, caring people who have suffered a tragic occurrence or loss. What they want and need and what is said, time and time again, is they want improvement to prevent a similar occurrence from happening to others. They don’t want other families to suffer the same circumstances and they understand that things go wrong with providers. They wish the providers no ill will and want them to learn from the experience. Many even understand that the responders are “Second Victims” and suffer as a result of the event.
I have taken many complaints and inquiries from members of the public over the years. Repeatedly, what I heard was “I don’t want to get them in trouble, I just want to see that it doesn’t happen to anyone else”. This comes across as sincere and very important to them. They want to tell their story, they want to be heard, and they want to spare others the same anguish they felt in their circumstances.
But what about the Paramedics in this case?
Well, we were not there. We have no right to judge. We don’t have an account. We have limited information. We jump to conclusions based on our past experience and bias.
The providers, paramedics in this case are “Second Victims”. No matter the decisions that may have been right or wrong, aside from the victims and their family, no on else will suffer more than the providers who look back on this event. They deserve support and empathy through the review of these circumstances.
What are Second Victims?
Second victims are healthcare providers who are involved in an unanticipated adverse patient event, in a medial error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base (Scott et al. 2009 p. 326)
Having lived through some of my own medical and decision making errors. I can attest that there is no retributive justice that can be any worse than what a provider is living with inside their own head as a result of an adverse event. Healthcare providers don’t enter this business or go to work each day intending to do anything wrong or lead to harm.
There are others as well that are second victims. The witnesses and family members for instance.
The first Bias: Outcome Bias
What is the difference between a “near miss” or as some would refer to “near hit” and an adverse event? The outcome! That is it.
Two providers can make the exact same determination, decision, treatment, error in similar circumstances. However, one has an adverse outcome and one doesn’t.
Let’s take this case for example.
We have heard in the media that some accounts question what was said, implied, done, and decisions on this scene.
If this happened with all of the same circumstances exactly as they occurred and the patient went to the hospital they did, and they survived, would this be looked at with a different lens? Perhaps a subtle discussion about penetrating wounds. Perhaps a some clinical quality audit feedback about optimal destination determination?
But, this patient died. We know the outcome. The outcome is the worst possible scenario.
Knowing this outcome is a bias. The witnesses, media, politicians, general public, peers and professionals all have opinions on what could have been done differently. They all have the privilege of not being in their shoes and knowing what happens at the end of the story.
This is the first challenge faced by leadership. There is immense pressure to answer and be held accountable for the actions and decisions made that night. There is pressure to prevent future incidences. There is political pressure to be accountable to the citizens of the city.
The leadership team has to block out this pressure in order to hear all accounts fully and determine facts without bias.
Yes, when humans make decisions, often for paramedics with conflicting and limited information, things sometimes go bad. But, that does not mean that they are bad people. Sometimes good people make bad decisions based on sets of circumstances and bias. We don’t know what else these paramedics have been through or experiences or what information they were presented with, only hearing all of the available accounts will contribute to a better understanding.
The Next Bias: Hindsight Bias
How many people look back at situations and consider that, now they look back, they have a better understanding? That is human nature. We all do it. When you have the benefit of hindsight, time, clarity, silence, reflection or “armchair quarterbacking” we can all make different determinations and decisions that seem much better.
What contributes to perceptions and decisions at the time of the event?
When people are in high stakes, uncontrolled environments making decisions based on various sources of information and perspectives decisions can go awry. This is not an excuse or a defense. Simply an understanding of human behaviour.
Dr. Daniel Khaneman a psychologist known for his book Thinking Fast and Slow discusses what he calls system 1 and System 2 thinking. System 1, fast thinking is based on our reptilian brain, fight or flight. It is designed to take in limited information and make life or death decisions. Emergency responders are trained to live in this system of thinking. They are often presented with pieces of information, patterns of signs and symptoms, hazards, that they must quickly assimilate into a decision that has life or death consequences for a patient or even themselves.
System 1 thinking however is flawed and subject to bias and error. An essential aspect of paramedicine is being able to control and overcome system 1 thinking and use some system 2 thinking to make more complex decisions.
An anecdotal observation that I have made of myself and various other coworkers who I would consider the best of the best, that I have learned from and worked with has shown that sometimes a scene can be managed much faster and more effectively by slowing down and thinking. Entering system 2 thinking. The true experts in paramedicine can take a step back, engage their system 2 thinking, process through problems, work out actions plans, devise and give decisive direction and implement a plan. The extra minute or so that it takes to bring calmness to a scene and think in this manner prevents trips, slips and errors. It ends up in a faster scene time and more effective and safe patient care.
So, what does this mean for the providers in this case?
Providers experience a range of emotions including frustration, anger, sadness, grief, and loss of confidence.
Second victims experience feeling of guilt and remorse that intrude into their lives. These providers require support and understanding for what they too are experiencing. Without this support these second victims may experience or progress to post traumatic stress disorder. This psychological trauma that a second victim may experience is deeply disturbing and distressing and can lead to the hallmarks of PTSD; Reexperiencing phenomenon, avoidance behaviour and hyperarousal. This results from the neuroscience of stress and psychological trauma.
This may not always be the case and one needs to be careful not to extrapolate normal emotions such anger or guilt about the situation as being PTSI or PTSD.
So, what needs to happen?
There will be an investigation. Multiple. Potential adverse events require reporting to the Ministry of Health in the Province of Ontario. This sort of investigation takes parallel paths that include the employer-employee relationship, the trade union, the regulator (Ministry of Health) and clinical stakeholder in Ontario the Base Hospital for clinical review.
This is not a pleasant situation for a paramedic provider and this is in addition to the emotions that they are feeling and the thoughts in their head about the events.
Yes, but somebody died.
Yes, they did. They were shot by a criminal.
The just culture pathways through an investigation can result in retributive justice (employee discipline) if there are things such as repeated personal performance issues or highly at-risk behaviours that are not warranted out of good intentions.
There is little value in employee discipline for clinical decision making errors of a non-maleficent nature.
Understanding the circumstances, what led to decisions, perspectives, behaviours, errors in judgement is what is most important to enhance safety and prevent future occurrences, not just for those involved, but all providers can benefit from learning in these circumstances.
An investigation can be very beneficial. It can, in fact empower the second victims. Again, the first premise of an incident investigation is that people did not come to work to do a bad job (Dekker 2006; Rasmussen 1990). What they did made sense to them at the time; otherwise, they would not have done it.
People do reasonable things given their point of view and focus of attention, their knowledge of the situation, and their objectives as well as those of their organization.
The second victim(s) did not know the outcome at the time (otherwise they would have done something to avoid it). Therefore there really is not need to assess the second victims actions based on the outcome. This is where the biases of outcome and hindsight are introduced.
There are inherent flaws with human memory and therefore reconstructing the incident from accounts and stories is the best approach. Stories from each persons open ended point of view including their assessments, decisions and actions.
Ultimately an understanding of how the second victim interpreted the situation needs to be reached.
To repeat from earlier, there are multiple perspectives, multiple factors and every witness or persons involved has their own truth to what occurred. All accounts of the situation contribute to the understanding of the incident.
Offering the second victims opportunities to contribute to the risk assessment and search for systemic vulnerabilities to help improve can be motivating and empowering.
The Leadership Perspective
As leaders in Emergency Services and Health Care we owe it to our team members and to those we serve to install a just culture and collaborative culture of safety in our organization. It is not easy, it is not a one time process. It is a continual and persistent practice and challenge. It is about the shared values of the organization and the care you have for your colleagues. It takes a bold leader to fend off pressure for immediate retribution and carry out an unbiased investigation.
As Ray Dalio says in his book Principles and often emphasizes, work is about having a meaningful mission with meaningful relationships.
Hamilton Paramedic Service is facing this challenge in this difficult time and circumstances. The victims family is suffering and the witnesses are second victims as well.
I honestly believe that whoever these paramedics are, they are good people who deserve the appropriate support, empathy and care that is evidenced by the research about second victims. We as society value their contributions and they are dealing with a broad set of emotions and stress. Even if there were egregious errors and flawed decision making.
Without being present at the scene we have no right to second guess, pass judgement, armchair quarterback or make any sort of determination about what happened that night.
Each person that was present has their own individual accounts of the circumstances.
HPS, MOHLTC and the Base Hospital has the unenviable task of conducting a complete investigation, considering all of the accounts and building learning opportunities and a collaborative culture of safety. And if circumstances warrant restorative or retributive justice. Just culture isn’t about letting people off, it’s about holding people to account to learn and improve and differentiating human errors and human factors from maleficent behaviour.
We must trust the leadership of these organizations to take account and have accountability to the victim as well as the second victims and all future patients they serve.
I hope this includes a disclosure process for the victims family and if necessary they can forgive and receive what seems to be a universal comfort and sense of closure, that there is always something to learn, improve upon and make better for those in the future.
Photo & Article Excerpts: The Hamilton Spectator
Dekker, S. (2013). Second victim : error, guilt, trauma, and resilience. CRC Press.