How you deal when you make a mistake

[scrubadubdub]

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So, today I was doing a lap chole, when we were getting in we had some bleeding which we felt was from abdominal wall, but nothing too worrisome, otherwise perfect textbook case. When we get out we look under the umbilical trochar, there's some clot, seems like drip down, we suction, look around, don't see anything, close, everything seems fine. Fast forward a few hours later the guy is in shock, we take him back to OR, has a mesenteric injury that definitely happened when I was trying to get into the abdomen, thought I was poking through peritoneum and must have instead poked through mesentery. Guy is still intubated, on pressors, otherwise a completely healthy guy. anyway, my question is, how do you deal with making a mistake that really hurts someone? Hopefully this guy will now recover and be ok, but I really hurt him, and it is 100% my fault. My attending was really nice about it, told me if this is the very worst thing I do in residency (I'm a third year, and so far it definitely is) then I'll be doing great, told me about the two patients he directly killed in residency, and I know complications happen and we're learning, but I just feel so awful. And I know I'll hurt someone else some day in the future. Maybe/probably kill someone. I've had complications, just never something that was so directly my fault, something where I blatantly did something wrong. It's just really hard to deal with and live with. Was wondering if other people felt the same way sometimes and how they deal with it.

 

[SouthernSurgeon]

So, today I was doing a lap chole, when we were getting in we had some bleeding which we felt was from abdominal wall, but nothing too worrisome, otherwise perfect textbook case. When we get out we look under the umbilical trochar, there's some clot, seems like drip down, we suction, look around, don't see anything, close, everything seems fine. Fast forward a few hours later the guy is in shock, we take him back to OR, has a mesenteric injury that definitely happened when I was trying to get into the abdomen, thought I was poking through peritoneum and must have instead poked through mesentery. Guy is still intubated, on pressors, otherwise a completely healthy guy. anyway, my question is, how do you deal with making a mistake that really hurts someone? Hopefully this guy will now recover and be ok, but I really hurt him, and it is 100% my fault. My attending was really nice about it, told me if this is the very worst thing I do in residency (I'm a third year, and so far it definitely is) then I'll be doing great, told me about the two patients he directly killed in residency, and I know complications happen and we're learning, but I just feel so awful. And I know I'll hurt someone else some day in the future. Maybe/probably kill someone. I've had complications, just never something that was so directly my fault, something where I blatantly did something wrong. It's just really hard to deal with and live with. Was wondering if other people felt the same way sometimes and how they deal with it.

You can dwell on it for a while. It's a natural feeling to be upset. In surgery we are in a unique position of being able to literally maim or kill with our mistakes.

The emotions you're feeling are normal.

What was suggested to me when I was in your shoes was take today, tonight, and let yourself feel like ****. But tomorrow, wake up and start figuring out how you can learn from this and move on. What would you do differently next time?

There's a good NYT editorial called Murderer in the Mirror that touches on a lot of what you are feeling:

http://mobile.nytimes.com/blogs/opinionator/2015/08/12/murderer-in-the-mirror/?referer=

 

[deleted547339]

So, today I was doing a lap chole, when we were getting in we had some bleeding which we felt was from abdominal wall, but nothing too worrisome, otherwise perfect textbook case. When we get out we look under the umbilical trochar, there's some clot, seems like drip down, we suction, look around, don't see anything, close, everything seems fine. Fast forward a few hours later the guy is in shock, we take him back to OR, has a mesenteric injury that definitely happened when I was trying to get into the abdomen, thought I was poking through peritoneum and must have instead poked through mesentery. Guy is still intubated, on pressors, otherwise a completely healthy guy. anyway, my question is, how do you deal with making a mistake that really hurts someone? Hopefully this guy will now recover and be ok, but I really hurt him, and it is 100% my fault. My attending was really nice about it, told me if this is the very worst thing I do in residency (I'm a third year, and so far it definitely is) then I'll be doing great, told me about the two patients he directly killed in residency, and I know complications happen and we're learning, but I just feel so awful. And I know I'll hurt someone else some day in the future. Maybe/probably kill someone. I've had complications, just never something that was so directly my fault, something where I blatantly did something wrong. It's just really hard to deal with and live with. Was wondering if other people felt the same way sometimes and how they deal with it.

If you don't feel that way when you hurt someone, it's time to hang it up.

Sorry man. That sucks. I'm not a surgeon, but I know i've hurt people and it sucks. The silver lining is that he may be fine.

Seriously, sorry.

 

[dpmd]

Totally normal response to a patient suffering because of a surgery you did (whether or not) you can identify how it is your fault or not (any patient that has an issue post op I assume I ****ed something up at least initially as I try to figure out what is going on). Only arrogant bastards don't give a **** or think they do not wrong.

 

[Smurfette]

Totally normal response to a patient suffering because of a surgery you did (whether or not) you can identify how it is your fault or not (any patient that has an issue post op I assume I ****ed something up at least initially as I try to figure out what is going on). Only arrogant bastards don't give a **** or think they do not wrong.

I echo this Sentiment 100%. When things don't go as planned, it's a very sober reminder of exactly what we do and that lives are at stake, even in so-called "routine" and common procedures.

The truth is, if you do enough of a given procedure, you will have complications. Identifying them and fixing them as best you can is also part of being a surgeon, and it's completely normal to beat yourself up about a complication for a couple days. I'd be worried about any resident or attending who didn't. the best thing you can do now is learn from it and know that next time, you may be able to somehow recognize it before the patient becomes unstable (**sometimes, there really isn't much of a hint that something is amiss).

 

[Winged Scapula]

All of us in surgical training or who have finished surgical training have hurt someone, whether we recognize it or not. Like Smurfette says, you do something often enough, even a familiar technically easy procedure, you will have a complication. We spend a lot of time complaining about patient factors, but even when a morbidly obese, smoking diabetic patient has a complication, even an expected one, we still ruminate.

We worry more about colleagues, students and residents who don't seem to care.

Your reaction is normal and human.

 

[scrubadubdub]

Thank you guys for all your responses. I know all of that is true, it's just a hard thing to go through. It helps to talk to people, even (or maybe especially) strangers. That article was great as well. I'm know I will use it as a learning experience and not make the same mistake twice. I wish this was something we didn't all have to go through, but I also know it is part of the honor of getting to practice this particular kind of medicine. As an update, the patient is extubated and doing well, at least for now, but I don't think I'll relax until he's eating, pooping, and walking out of the hospital.

 

[SLUser11]

Thank you guys for all your responses. I know all of that is true, it's just a hard thing to go through. It helps to talk to people, even (or maybe especially) strangers. That article was great as well. I'm know I will use it as a learning experience and not make the same mistake twice. I wish this was something we didn't all have to go through, but I also know it is part of the honor of getting to practice this particular kind of medicine. As an update, the patient is extubated and doing well, at least for now, but I don't think I'll relax until he's eating, pooping, and walking out of the hospital.

I think it's important to find out what happened, why it happened, why it wasn't identified intra-operatively, what will be done different moving forward, etc. You're going to feel bad for a while, but you'll ultimately recover, and I think it's important that you learn from your mistake, and then perhaps take it a step further and allow others to learn from your mistake.

There are certainly some things that just simply happen, e.g. SSIs, and I guess I've heard many statements over the years that say "everyone has complications, and if you don't, then you haven't done enough of them." However, a trocar injury that almost killed a patient doesn't fall under routine, expected complications. This should be a big wakeup call to you, as a PGY 3, about how fallible we are as surgeons, and how fragile patients can be. It can be a defining moment in your early career. Also, I want to point out that it's not 100% your fault. If you're being supervised by your attending, they must ensure you use safe techniques for access, and they must be able to identify major mesenteric injuries.

What technique did you use to gain access?

Was it a trocar injury during placement? Veress? Instrument or camera used as a dagger? Are you sure you know what happened?

What patient characteristics were different than normal (e.g. habitus/coagulopathy/previous surgeries)?

In retrospect, were there any other hints that things were going wrong?

Why do you think you didn't see a bunch of blood accumulating in the abdomen?

How much clot was there when you looked at the abdominal trocar?

Why is the patient on pressors now that you've controlled hemorrhage? Was there delayed recognition in PACU?

 

[mmmcdowe]

You will make mistakes out of ignorance and due to lack of skill and there is no way to avoid it. Comfort yourself by preventing mistakes due to negligence.

 

[balaguru]

My 3 principles regarding complications:

1. Accept responsibility. Don't blame the instruments. Don't blame the OR staff. Don't blame the patient. As a trainee, ultimately your attending was responsible, both for the immediate injury and the failure to recognize the source of bleeding during the first trip to the OR.
2. Show remorse. This doesn't necessarily mean even saying sorry which is controversial in the medicolegal sense. You'll have to figure out how to do this going forward. As a trainee run any sort of discussion that you have in mind with your attending. They are ultimately on the hook for the complication and may not be comfortable with you falling on your sword in front of the patient/family. Showing remorse can be as simple as adopting a contrite tone when explaining the complication and being attentive to the patient's needs and vigilent for any subsequent secondary complication.
3. Learn something. Run through the events in your head and search for your blinds spots. Come up with a plan to reduce the chance that this could happen again. Hopefully, you have a legit M&M in which you can discuss this with your faculty and colleagues.

It's a balancing act: your bag of complications should be heavy but not immobilizing.

BTW, I have had 2 trochar injuries in my career--not as consequencial as yours but still not acceptable to me.

 

[dpmd]

I say I am sorry that this happened as I discuss what is wrong with them now and what I am going to do to fix it. After reading through stuff from my malpractice insurer and from ACS I don't really fear the word sorry. Has been received well thus far by patients/family members. But as a trainee it is vital to discuss with your staff before talking to the family.

 

[MediCane2006]

To OP but also to all the surgical trainees reading this thread: You WILL have complications. They are awful. They may be a direct result of your ineptitude (which make them even harder to face).

There is a ton of good advice from surgeons much more advanced than me in this thread.

-Accept responsibility. This is a really hard thing to do as a trainee. There is a feeling that accepting responsibility is acknowledging that you are a bad surgeon. This is not (necessarily) true. But acknowledging that you are the surgeon who made the mistake is a huge, humbling experience as a physician. It forces you to confront your fallibility and review the reasons why this happened. Fortunately, at most academic places there is an M and M process during which the relevant literature and teaching points are discussed. You can talk about why putting a chest tube through an old chest tube scar (and thereby plowing through the adhered lung causing a major parenchymal injury) is a bad idea in retrospect. Or why even if you think you see a critical view you can still sometimes clip the common duct. (not that I would know anything about these complications obviously).

-Think about these patients as you move forward. Obviously, although no one likes to talk about it, these patients are all subjects in a teaching institution. Honor their donation by remembering the lessons you learned. There is a really good reason why I will never put in a brachial a-line no matter what the complication rate someone quotes me, and it's because of the patient who drew the wrong side of those odds one horrific weekend on ICU call. No one wants to have a complication, but the question is, WHAT ARE YOU GOING TO DO DIFFERENTLY to make sure this complication never happens again?

-Don't let it paralyze you. Easy to say. I know. But every surgeon has complications. Once you move through the prior two steps, accept responsibility and decide what you are going to do differently, you gotta move on. The bad surgeons are either the ones who refuse to believe they need to change based on their complications, and the ones who let their most recent complication dictate their practice.

 

[Thanatos]

So, today I was doing a lap chole, when we were getting in we had some bleeding which we felt was from abdominal wall, but nothing too worrisome, otherwise perfect textbook case. When we get out we look under the umbilical trochar, there's some clot, seems like drip down, we suction, look around, don't see anything, close, everything seems fine. Fast forward a few hours later the guy is in shock, we take him back to OR, has a mesenteric injury that definitely happened when I was trying to get into the abdomen, thought I was poking through peritoneum and must have instead poked through mesentery. Guy is still intubated, on pressors, otherwise a completely healthy guy. anyway, my question is, how do you deal with making a mistake that really hurts someone? Hopefully this guy will now recover and be ok, but I really hurt him, and it is 100% my fault. My attending was really nice about it, told me if this is the very worst thing I do in residency (I'm a third year, and so far it definitely is) then I'll be doing great, told me about the two patients he directly killed in residency, and I know complications happen and we're learning, but I just feel so awful. And I know I'll hurt someone else some day in the future. Maybe/probably kill someone. I've had complications, just never something that was so directly my fault, something where I blatantly did something wrong. It's just really hard to deal with and live with. Was wondering if other people felt the same way sometimes and how they deal with it.

Its tough but like others have said, these things will happen.

I think its very important to point out that after the case you were vigilant, returned promptly to the OR, found the injury and fixed it. You won't ever be complication free...none of us will. But I think its our response that really matters....you have to be willing to accept the fallibility and have a low threshold to man up, call the attending and family and go back to the OR figure it out. Even though you had the complication you did the right thing by identifying it quickly and treating it appropriately.

This is crucial.....when I was on peds cardiac we had an attending who would say if the patient isn't doing well, the first three things on your differential are "imperfect surgery." Now in his field the complications come at you fast but present early....thats not always true in other specialties. I remember quite well though a colorectal surgeon we had who always put anastomotic leak at the bottom of his differential.....he would jump through hoops for a day trying to explain that the abdominal pain, distension and tachycardia were all independent manifestations of medication side effects and poor fluid management by us, his lowly residents 😉 So don't be that guy, and we all know someone like that.