What goes through a surgeon’s mind after a complication

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 screwup, 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.

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 …

Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.

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  • SherryH

    So, what happened to your patient? And did you try to make things right?

    • Sid Schwab

      I should have answered your question as a reply. Instead it appears way above. What I said was “This post was the first of two, on my blog, from several years ago. I assume Kevin intends to publish the second part, which explains in detail. But of course I tried, and succeeded, in making things right. Who wouldn’t?

      • SherryH

        Life has taught me that a lot of people don’t own up to their mistakes. Sadly, some people wouldn’t make things right. It wasn’t meant to be a comment on your profession, just on human nature in general. I’m glad to see that you did make amends, and I look forward to reading part 2 of your story.

        • rbthe4th2

          Same here. The thing is, its only some doctors like that. If I see one that makes a mistake and tries to fix it, owns up, you best believe I let them and the admin and everyone else know, to do this now, says a lot for them.

  • Sid Schwab

    This post was the first of two, on my blog, from several years ago. I assume Kevin intends to publish the second part, which explains in detail. But of course I tried, and succeeded, in making things right. Who wouldn’t?

    • rbthe4th2

      My old surgeon. He certainly ruined my relationship with another couple of doctors and I’ve had problems since then thanks to him. The reason why so many believe in blacklisting …

  • Lisa

    I agree; I’ve had complications after surgery although none of my surgeons have made a surgical error (that I am aware of). The complications were not anyone’s fault – just things that happen.

    In one case, I developed a minor staph infection in my incision. My surgeon put me on antibiotics immediately and watched me very carefully. The infection resolved quickly. I know friends who developed infections after surgery and had more problems than I did. One difference is their surgeon did not see them immediately when contacted about a potential infection.

    Another surgical complication I’ve had is cutaneous nerve damage. I have a largish numb patch on my thigh – It doesn’t effect functioning and I don’t worry about it. I was informed (pre-surgery) that this is a possible side effect of a total hip replacement.

    What I don’t understand is why some doctor’s won’t admit that the surgery they performed can lead to permanent side effects. I am specifically thinking about lymphedema following surgery for breast cancer. It is very common for breast surgeons to downplay a patient’s chances of developing lymphedema and when the patient presents with symptoms that suggest they are developing lymphedema the surgeon will not provide the appropriate referrals so the lymphedema can be treated. Bah…

    • DoubtfulGuest

      Good points, Lisa. I also feel that surgeons should be upfront about potential complications. Supposedly one argument against this is that patients will become anxious, but I actually felt more confident with my hysterectomy surgeon after he explained possible complications ahead of time. This was the newer TLH procedure. He told me of two past incidents with complications and about the additional training he received to prevent those in the future. He also gave me examples of how he would fix a complication. I did understand there was a very small risk of death or some other serious complication that could not be reversed.

      I really felt this discussion increased the trust between me and him. For his part, he knew I understood the risks and that I was holding him to a high standard but not expecting perfection.

      I thought I read that lymphedema is pretty common after BC surgery? I can’t understand the justification for delaying treatment and not being upfront about this. How are patients supposed to willingly take on these risks if they’re not fully informed? How can we have reasonable expectations of docs if they’re not upfront about their limitations?

      • Lisa

        Lymphedema is pretty common after breast cancer surgery and for that matter after many cancer surgeries where lymph nodes are removed for staging. And I agree with your questions.

  • Anne-Marie

    They are, but there can be overlap if the complication is not promptly recognized or is clinically mismanaged. Then it can morph from “known complication” into errors of judgment, e.g., misdiagnosis, incorrect treatment, failure to assess, failure to adequately monitor, delay in treatment that negatively affected the outcome, etc.

  • Patient Kit

    I do understand that all surgery comes with risk and no human is perfect (not even the best surgeon in the world), but I have to agree that “there’s been a complication” has a decidedly different implication and tone than “I made an error.”

  • Patient Kit

    I can sincerely empathize with your angst and pain about accidentally hurting a patient you were trying to help. No matter how hard we try, no human being can be absolutely perfect all the time. As a patient, I feel very lucky that I’ve been through four major surgeries without any complications.

    But I have a related question: When a surgical error causes complications that require a second surgery and a longer hospital stay, how is the patient billed by the surgeon and hospital for that second, fixing the mistake surgery?

    • Sid Schwab

      Good question. In general hospitals charge for the care as they would for anything else, unless the problem could be considered directly hospital-related; in which case, they might or might not.

      On those rare occasions when I had to re-operate for a problem, maybe three or four times in a thirty year career, I generally didn’t charge. I’d say that’s not a universal behavior. In fact, it got me in trouble one time when I had to take someone back to control (not very serious) bleeding (patient went home on schedule): I didn’t charge, so the anesthesia department sort of made up a billing code, like “repair of artery,” which was not what I’d done. The patient filed a suit on the basis of my lying to him. His lawyer hadn’t even asked for the records first, which made it clear that I hadn’t lied; and the anesthesia department billing person agreed they’d just picked a surgical code without checking with me.

      As I wrote, living with complications is bad enough; having lawyers circling and willing to do stuff like that, makes it even worse. The above-mentioned suit went away easily, of course; but not before a sheriff strode into my office in front of a roomful of waiting patients, and handed my secretary a subpoena, or whatever it was…

      • Patient Kit

        If my surgeon came to me, human being to human being, and told me openly and honestly that he made a mistake that caused some complications, that he was sincerely sorry and going to do everything possible to fix it, I think I could deal with that in, not all but, many possible situations. However, I’d have a huge problem accepting that my surgeon’s mistake was going to cost me an extra $50,000 or so for a second surgery and longer hospital stay.

        What your anesthesiologist did was wrong. I’m not surprised though. As much as I appreciate what they do, I’ve had more problems with anesthesiologists as a group than any other kind of doctor. Twice, I had major surgery for which my Blue Cross at the time paid 100% for the hospital, the surgeon and everything else but the anesthesiologist. The anesthesiologists tried to bill as if I was uninsured or they didn’t accept insurance. Hello? If you want to admit me to the hospital for surgery, somebody should mention it during the pre-op prep if anesthesiology isn’t going to be included. I appealed both times and BC eventually paid the anesthesiologist (although I can’t remember how much). But I shouldn’t have had to go though those fights. Similarly, a friend recently had her first colonoscopy. The doctor and procedure were 100% covered by her insurance but the doctor’s office used an out of network anesthesiologist and failed to mention it. My friend got an unexpected $3,000 bill from that anesthesiologist. Shouldn’t docs who use our insurance send our blood to labs that accept our insurance and use anesthesiologists who accept our insurance. Or, at the very least, mentioned upfront that they don’t? But I’m off on a tangent (again).

        • Sid Schwab

          I probably didn’t explain the anesthesia issue well enough. Normally, in our practice, the anesthesia billing staff (not the docs) used the code for the operation based on the surgeon’s bill. Since I didn’t submit a bill, the staff picked one they thought applied. Not a deliberate attempt to deceive.

          • Patient Kit

            Ah! Thank you for clarifying and correcting my misinterpretation. Too late to prevent my anesthesiologist rant though. ;-)

          • DoubtfulGuest

            There’s a very nice anesthesiologist who posts on Kevin, FYI. Well, one that I know of, probably more.

            I hate to break this to you, but this doc is one of the numerous posters named “guest”. :/

          • Patient Kit

            To be clear, I don’t hate anesthesiologists. I’ve had some very good anesthesiologists and know firsthand how important what they do is. I’ve never had any complications from general anesthesia during any of my surgeries. And when I had to be face down on the table for surgery on my severely ruptured Achilles tendon, I told my anesthesiologist that, if I was going to be in that position, I was going snorkeling in crystal clear Carribbean waters and she went with it. I appreciate the serious cocktail of drugs they are putting through my body, including my brain. I hate pain and love anesthesiologists. :-D That said, for some reason, they are the single category of doctor that I have had the most billing hassles with. >:-(

            LOL! I didn’t realize that one of our “guest”s is an anesthesiologist. In my mind, they are all merged into one anesthesiologist/psychiatrist/surgeon/RN/oncologist/primary care doc. ;-p I’ve given up on trying to keep straight who the various “guest”s are here.

          • DoubtfulGuest

            Oh, I didn’t think you sounded hateful at all. I’ve also had billing difficulties with them…there’s some communication gap in those situations and I’m not sure how it works or how to fix it.

            It’s just, you know, during hard times, the nice doctors can seem like rare birds so I feel compelled to point them out, like: “Ooh, look! There’s another one!”. I’m taking a class these last few weeks and there’s a physician in the group. Last time she went out of her way to talk with me, and didn’t bite my head off or anything. I wasn’t expecting that.

            Okay on the “guest” issue. I don’t mean to muddy the waters any further…;)

          • Patient Kit

            Oh, good. I’d hate to sound hateful. I’m fine with sounding frustrated and angry sometimes though. ;-)

          • EmilyAnon

            I think there’s a hospitalist in the ‘guest’ mix too. Or maybe they’re the same person putting on different hats for different discussions. Who knows.

          • Lisa

            A quick comment, I think the reason that there are have billing hassles with anesthesiologists is that they are ‘assigned’ to you by the hospital or surgical center. You usually don’t get a chance to meet them before your surgery and certainly don’t get to make sure that they accept your insurance or that they are a preferred provider (my insurance reimburses at two rates). That said, I like anesthesiologists too. :-)

          • Patient Kit

            I think you’re right that that is part of the dynamic that causes the problems. But it needs to be addressed and fixed. If I’m on a gurney going to surgery in a hospital that accepts my insurance to have surgery performed by an orthopedist who accepts my insurance, shouldn’t the hospital or doctor assign an anesthesiologist to my case who accepts my insurance?

            If not, whose responsibility is it? I’m on a gurney in pain and/or drugged up without a phone. I can’t go shopping for an in-network anesthesiologist at that point. It just adds a whole other layer of unnecessary stress to surgery to know that the anesthesiologist problem looms. It’s not exactly “patient-centered”. It’s more like a captive audience opportunistic ripoff. Like what are the patient’s options? Accept the cost of whatever “direct pay” anesthesiologist is assigned — or what? — opt to have major surgery without anesthesiology?

            All of my billing problems with anesthesiology, btw, were with a very good Blue Cross plan. I had unlimited physical therapy with no copays but access to an in-network anesthesiologist was an issue. No anesthesiologist billing issue for my recent GYN ONC surgery while covered by Medicaid.

          • Lisa

            in 100% agreement that the problem needs to be fixed. I’ve heard many stories about this issue.

          • Patient Kit

            In addition to my own experience, I too have heard way too many stories about anesthesiologist billing issues — too many to believe it’s not intentional and strategic — like they have you over a barrel and are going to take full advantage of peeps who are sick or injured enough to need surgery. Not exactly the US healthcare system at it’s finest.

          • DoubtfulGuest

            Strategic on whose part, though? I agree with you that it’s seriously messed up. It’s just, I imagine for the anesthesiologists, it could add more uncertainty for them about ever being reimbursed? I’d like to learn how the assignment works, if it’s just a schedule-based thing, or what?

          • Patient Kit

            It happens so often that I figured it was a ploy by anesthesiologists to charge more than most insurance contracted fees. But maybe you’re right. Maybe it puts a lot of their billings in the contested pile and delays any payment longer. At any rate, it’s a big stress that no surgical patient needs and I’d love to know why it happens so much.

          • SherryH

            Everything in hospital/facility care is an opportunistic rip-off. My “care” for an injury has cost me thousands and I’m not any better off than I was when it started. Same injury, same pain. But now broke.

          • rbthe4th2

            ROFL

        • rbthe4th2

          Amen. I could probably think that Dr. S is right, maybe 4 mistakes in a surgeon’s career. I don’t see where the hospital shouldn’t eat the cost of that. I mean that’s really not a lot of $$ when it comes down to it. I’ve seen profits of a local hospital and they can afford 4 surgeries multiplied by the number of surgeons they have.

  • Patient Kit

    First, I’m sorry that you are going through this. It’s pretty gutless for your surgeon to send his resident to tell you what “happened” instead of looking you in the eye and telling you himself. I have little respect for that kind of gutless behavior. As a vet of surgery myself, like you, I understand that there are no guarantees and complications (and errors) happen. But I totally agree with you that a good doc, in this situation, should follow up personally with his patient to see how they are coping with the complication and offer support and suggestions for dealing with it.

    • rbthe4th2

      Agreed.

  • Anne-Marie

    I’m very sorry for all of this – first, for the fact that you’ve had complications, and second, for the lack of support and acknowledgement from the doctor.

    I would recommend visiting the website of Medically Induced Trauma Support Services. There’s a lot of helpful information there, and it may help you feel a little less alone.

    http://www.mitss.org/

    I think that if clinicians spend too much time thinking about the fallout to their patients who experience an adverse event, it can become overwhelming and even paralyzing. So they adopt some distance as a way of coping so they can keep moving forward. I understand it but I wish they would recognize that at least they can walk away from it to some extent. We can’t, and we often need continuing help in order to truly heal.

    • Suzi Q 38

      Yes, I am one of the unfortunate ones that have had an adverse effect after my surgery. I was fine before my surgery. Yes, I was overweight, but I was not in pain, nor did I have any nerve sensations.
      After my surgery, my serve problems started while I was recovering from that surgery. I noticed I was weak and had difficulty standing after surgery. I thought that it was just what happens after a hysterectomy. Later, I felt tingling in my hands and feet, and a month later, the tingling and numbness went to my inner thighs and legs.
      I reported this to the nurse and the surgeon, who told me to “wait and see” if it went away. I still could walk, so since he was not alarmed, why should I be alarmed?
      I had no idea that these nerve sensations would become permanent and I was heading towards paralysis.
      It took a lot of pushing to get the surgeon to get me a referral to a neurologist. The time from first reporting it to him to my referral was about 5 months.
      I finally had to call the nurse navigator to facilitate my neurology evaluation.

      The neurologist there took his time, too. My problem was I was not a huge complainer, and I looked fairly healthy.

      My back and c-spine was really messed up. If I had at least been listened to and taken seriously, It could have saved me from my present life of constant numbing sensations and pain. I finally got my diagnosis about a year and a half after I first reported it. I wish I had realized how ill I was.

      I finally ran to another hospital. That hospital listened to my story and could not believe I was left without a full MRI and a diagnosis for that long. They told me “we regret to inform you that your prior physicians waited too long to diagnose your condition and give you your surgery. You may not improve, but at least we can stop the leg weakness from progressing.”

      I truly feel that my surgeon stalled because he was concerned or fearful that it was an adverse effect of his surgery.

      After all that was said and done, I had to come to terms with the fact that maybe it was, but maybe it wasn’t.
      I could have had neck and back problems before the surgery, and the surgery itself exacerbated an undiagnosed prior condition.

      The best he and the hospital could have done was not “drag their feet,” but get me the proper care ASAP, so I wouldn’t worsen or be permanently paralyzed.

  • rbthe4th2

    Good luck. I have seen maybe one surgeon in my life who would do what you and I and others look for. Online is another story, I’ve seen several that I wish I could be their patient because they do have the courage, honesty, and self respect to do so.

  • Dr. Cap

    We all make mistakes. Hopefully the bile duct ones are recognized, or patient safety can become an issue. Speaking in general terms, I believe the papal sin is to deny and/or deflect. Or worse yet, blame (the patient) others. He was obese, her sugars were uncontrolled, anesthesia extubated too soon. We cut other people for a living! A zero complication rate only means you have not started yet. Eventually something’s going to go wrong. Or not quite right. Whatever.

    Timely this posting is, as I am recently dealing with an Oh Fudge moment (not what actually went through my mind)– not life threatening, and was discussed as a risk with the patient. None of that makes me feel any better about it. The only thing that does is the fact that I looked her in the eye and said sorry. And that I did not yet have a great explanation but that I would fix it for her pronto. Meaning now. Not during regular business hours.

    I hope she forgave me. I think so…

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