“Did I just kill my patient?!”
By: Education of a Knife
“Fuck!”
I had just pried my eyes open and had the realization of exactly what time it was. I was going to be late again. I jumped out of bed as fast as my stiff and weary body would allow, threw scrubs on I was mostly sure were clean, ran a brush through my hair so I didn’t look totally disheveled when I had to look like professional in a few minutes, and ran out the door.
I was in my third year of surgery training and it was my first rotation as the chief resident. The chief resident on service is the one in charge, so to speak. The one in charge of the resident team’s successes and, more importantly, their failures. Basically, it’s a “fake it until you make it” type of moment. The majority of the time, it felt like I had no idea what the hell I was doing, but I was three weeks in, and I started thinking to myself “yes, yes, you can do this.”
Today I was late, the second time in a week. As I turned the key in the ignition of my car, I paused and made the responsible decision not to take the extra five minutes to stop for coffee. I always, always had my coffee in the morning. It was a physical and emotional crutch for me to make it through the 5 to 7 AM hours, and was a terrible habit. But today, I was a chief resident. I was going to be responsible, and try to not be late.
I pulled into the hospital and ran to rounds. Things moved slowly that morning, like I was wading through molasses. The synapses in my brain fired just slow enough to feel the delay, leaving the world foggy and muted. I walked to the operating room and desperately tried to shake that feeling.
I was doing a new operation that morning, one I never performed in its entirety: a laparoscopic Nissen fundoplication. A bunch of fancy words for wrapping the stomach around the esophagus so that people don’t get heartburn and everything terrible that comes along with that. I had done parts of it, but never the whole thing. It is relatively straight forward, but of course, there’s a catch; right behind the esophagus is the aorta. You have to make a space between the two to complete the operation, without making a hole in either one, especially the aorta.
The case started, same as always. Prepare the patient. Prep the skin. Drape. Take my position at the table. Make an incision. Everything was moving smoothly. Then, while trying to make the space between the esophagus and aorta, it stuck. I spread the tissue, but it would not give. Another spread, this time with a little more strength, and still nothing. I received a little encouragement from my attending, as he said, “That’s right, you’re almost there.” I felt the nervous energy spike in my stomach. One more spread, with a bit more vigor. Then, blood…and nothing but blood. Blood pouring out behind the esophagus, obscuring everything in view.
I immediately made eye contact with my attending. I could read the concern, even with a surgical mask covering his face. We stared at the monitor for what felt like an eternity, watching the pulsatile blood flow.
“Open?” I said, nervously.
“Yes,” he replied, pushing the operating room immediately into hyper-drive. Incisions became larger. Instruments moved back and forth. My hands moved quickly, instinctively making motions and taking actions that were automatic. But my head, my head was full of questions.
“Did I just put a hole in the aorta?”
“Will he make it out of the operating room?”
“Did I just kill my patient?”
These questions looped through my mind on repeat as we opened the belly, cleaned out all the blood, found the aorta, and examined it so very carefully. Except there was no hole. We stared into this man’s abdomen, flummoxed. Where did all the blood come from?
No doubt there was bleeding. We evacuated nearly 2 liters of blood just to see anything when we entered the abdomen. But where was it coming from?
We meticulously examined every square inch, trying to find the origin. “Maybe it was a small arterial branch,” my attending said. We continued staring for what seemed like forever, until we were convinced nothing would bleed or was bleeding.
We completed the operation. We closed the incision, still with unanswered questions in my head. The room was very quiet, except for the white noise raging in my brain. I helped transport the patient to the intensive care unit, staring at his blood pressure, waiting for the other shoe to drop, and the bleeding to start again. After delivering him to his room, I walked out, eyes down. I could feel the tears about to bubble up out of my eyes. I had to get out of there.
No one could see the chief resident crying. My pace increased, walking as fast as I possibly could. People said hello to me and I kept walking, staring directly at the dingy color-blocked floor, not breaking my stare until I reached a stairwell in the back of the hospital. Once there, I could not contain it anymore. Tears ran down my flushed cheeks. I audibly sobbed, sitting on the stairs, crying my eyes out. It was the first time in the operating room I potentially hurt a patient. Not only hurt, but feeling I nearly killed them.
It’s not a feeling anyone can truly prepare you for, the feeling of unintentionally hurting someone. But it’s a feeling we all universally experience at some point in time during training. We are human, and we make mistakes. Tissue planes can be unclear, anatomy can be unforgiving, and complications happen. However, what happens to the person behind the mistake? How do you recover from that feeling of hurting your patient, the very person you took an oath to protect?
I sat in that stairwell for what felt like forever. I had to go back to the operating room. We had another operation to do, another patient that needed care and my undivided attention. Eventually, I picked myself up, and composed the liquid pile emotions on the floor back into the rigid chief resident I was. I took a deep breath and walked back into the light of the real world.
I ran into my attending in the hallway outside the next operating room after I’d collected myself. Unprompted he said, “You know, you didn’t do anything wrong.” I could feel tears start to well up again so I swallowed hard, bit my tongue, and nodded my head silently in recognition of the statement.
“You know, I never had my fucking coffee this morning,” he said, “And I always have my coffee. You want a cup?”
I started to laugh. Yes, of course, I wanted a coffee. While they were prepping our next patient, we sat in the operating room lounge, sipped on slightly burned coffee in Styrofoam cups, and talked about life.
It might have been the most delicious cup of coffee I’ve ever had.
Education of a Knife is a doctor, surgeon, and aspiring writer at a new blog focusing on surgical training and issues in medical education. Please give it a look at EducationofaKnife.com and follow on twitter at @CutSutureClose.
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An awful, familiar story.
And a word from the wise, it WILL happen to you. It’s only a question of when.
I’ve made mistakes, and I’ve seen the careers of some of my juniors crushed by the mistakes they’ve made. It’s a very lonely place, and self recrimination is ugly.
Mistakes happen in healthcare and sometimes you’ll blame yourself – sometimes rightly so, sometimes not.
But healthcare has a really bad habit of putting junior people in high risk positions. We serially fail to put a safe, protective process in place when it comes to hazardous procedures. Because we don’t have a universally accepted method of recording what our juniors are able to do, we can’t validate when they are capable of practicing independently.
So when things go wrong, we doubt ourselves.
Wouldn’t it be better if we could fall back on a clear record of our training, the seniors who had signed us off, a transparent record of our experience and outcomes? Wouldn’t that make it easier to console ourselves that we’d done everything we can do to prevent accidents occurring?
Because for some reason, our industry is always reactive. We only realise that we should have been more robust in our systems when something bad has happened, and it’s too late.
That’s why verifiable portfolios of your skills, like http://osler.community were invented – so you can prove your training history and defend yourself when you need to
There is a better way – make sure everything is on your side.