Wednesday, January 31, 2007
It's Complicated: part one
One of the hardest things about being a surgeon is the inevitability of complications. It's true for any doctor; but with surgery, it's as if they are lit in neon and given a soundtrack. At least to me. Aiming for perfection (as do we all) and beating myself up (more than healthier people) when I miss the mark, I found bad outcomes of nearly any magnitude deeply disturbing. The big ones are there for lots of people to see: nurses on the surgical floor or ICU, operating room personnel when you have to re-operate. And of course, the patient. The family. My family, for that matter. Smaller problems might just be between me and the patient; but they still are painful. Carrying the responsibility for having done harm to people who gave me their trust can be nearly too much to bear. Thankfully rare, it's never been easy. Nor should it be.
I don't know the extent that I speak for other surgeons in this matter. I actually believe I took it too hard, and too personally; so what I say (which I'm sort of anxious to find out myself) may be fairly singular. But I got a specific request to tackle the subject, and I think it's an excellent one. So here goes.
There are two cardinal sins, in my estimation, for the general surgeon. The first, the sine qua non of a surgical screw-up, is injuring the common bile duct. Nailing the bowel with a suture while closing an abdominal incision is the other. Each tends to bespeak carelessness, and I'm sorry to say I've done both. Only once each, thank God, in what I'd conservatively estimate to have been around ten thousand operations (not all, of course, subject to those particular errors.) Actually the cardinal error -- more like the pope error -- of bile duct injury is to do it and not recognize it at the time. THAT, I've never done. Unrecognized bile duct injury can lead to a tragedy for the patient. If you're gonna ding it, at least see it at the time and fix it. That usually works out ok.
In the community of my first job as a surgeon, each newbie was subjected to a monitoring process in which every other surgeon in town was to scrub with him/her at least once at to render some sort of judgment. So the first time I was able to do a case unmonitored, I had the referring doc assisting me on a very routine gallbladder removal. It was the classic situation for injury: the easy case -- when the going is tough, you tend to have all the feelers out for problems. (I'd add, apropos a comment I received on my mini-gallbladder post implying it was the worst of all possible worlds, this was in the days of the big incision, and well before laparoscopic surgery.) My patient was a tiny woman, with tiny ducts. Her gallbladder had practically no length of duct connecting it to the main bile duct, so I thought I was dissecting the cystic duct (normally much longer, it's the tube that connects the gallbladder to the common duct), when in fact I was working my way down the common duct. Somewhere along the line, I discovered I'd cut it clean in half. As my heart sank and my hands got clammy with the realization, my forehead and armpits drenched themselves with sweat and I told the referring doc I'd be wanting to get my partner in to help at that point. He was only too happy to vacate. I repaired the duct -- among the smallest I've ever seen -- over a baby-sized T-tube, drained it, and closed up. And for the first time as a real doctor, I had to face my patient and tell her what happened.
It's excruciating. I hate everything about it. There is a very real temptation -- to which, even in this age of attorneys under every rock, some people still succumb-- to fudge it, not to tell it like it was, to protect oneself. In my case, I think, the urge is motivated less by fear of lawsuit than of confronting my own inadequacy. And the acute awareness that I'm telling a person things will not be as she expected; that her life could be very unpleasant for awhile. It's not what she signed up for, and it's my fault. Face to face. You're screwed. My fault.
I doubt I could successfully bullshit a person if I tried. My car got stolen when I was in med school. In the glove box was a small amount of what might be called an herbiferous stimulant (that it was small and had been in my glove box for months bespeaks the extremely limited use to which it was put.) For what may be the only time in the history of the local police, they found my car, and called me to pick it up at the station. Finding the glovebox contents strewn about the car, I noted it was all there; except for the one item. To the query if anything was missing, I said no. Couple of days later, there were two cops at my door, holding badges at eye level (narcotics boys) and asking for me. Had they just graduated from cop school, had they never seen a guilty person in their lives, they'd have known I was as guilt-ridden as if I were holding a bloody dagger. They displayed (holding it by a string: no fingerprints) the Alka-Seltzer bottle which held the offending material, and asked if I knew what it was. "Well," I said. "You guys being here and all, I suppose it's some sort of drug...." Fortunately, they also knew that the car had been stolen and there was no way to pin the contents on me. A stern warning was what I got, as my future career and my father's wrath passed before my forebrain: the one waning, the other waxing. I'm a lousy liar. (And since then [well, not too long after] a confirmed non-user.)
I told my patient truthfully what had happened, but I was not above trying to put it in the best light. Her anatomy was unusual, I explained, with her gallbladder so close to the bile duct that removing it left the duct damaged. True. But passively stated. To my retrospective regret (because it was less than entirely forthcoming), I glossed over the fact that I hadn't recognized the anatomy until I'd done the damage. I didn't lie. Yet I didn't resist the urge to sugar coat it. She was disturbed, but not beside herself: ultimately she had to put up with a capped-off tube with no drainage for three of months, after which it was gone and she had no further problems. (Being just out of training, I wrote to my professor to ask his advice about how long to leave the tube. In doing so, I said "I was recently called upon to repair a bile duct...." It was not untrue. I hoped he'd assume it was someone else's injury. He never said otherwise, but he was a very wise man.) It could have been much worse. As to the conversation I'd had with my patient, it's weighed on me ever since, and it was a long time ago. So many issues are at play in such a situation, it's hard to enumerate them, let alone fully understand them. I'll try.
The suture thing was quite different: the whole spectrum of terribleness, way worse for everyone. It had been a routine colon operation, and she'd gone home quickly, doing fine, only to come to the emergency a few days later, sick. My clamminess didn't take over right away, because my first instinct was to try to fool myself, to convince myself it wasn't what it was....