Wednesday, July 30, 2008

Takebackers

A transplant surgeon I trained under in Chicago once told me that one of the worst errors a surgeon can make is failure to return a patient to the OR in a timely fashion. In transplant surgery, you're dealing with coagulopathic, extremely ill patients who undergo commando abdominal operations; post operative bleeding can be a commonplace occurence. It was no big deal for those guys to bring a post op liver transplant back to the OR to evacuate a hematoma, even multiple times.

For most general surgeons, however, a return to OR is a major complication. It gets you on the Morbidity and Mortality list. The QA committee sends you a letter. It's a sign of error. You did something wrong. You closed the skin leaving something undone.

It's human nature to deny any intentional wrongdoing. You run the case through your mind. Everything seemed fine. It was dry when you closed. The anastomosis looked beautiful. You checked the ureter. The clips seemed in good position on the cystic duct. So why is the patient not doing well? Could it possibly be related to something I did?

Well, yeah. It's always a possibility. And if the patient is leaking or bleeding or whatever, it isn't going to get better all by itself. In fact, the longer you wait, the worse the final outcome will be. It's amazing how a normally astute general surgeon suddenly transforms into a psychiatry resident in the post-operative period when things start to deteriorate. Peritonitis on exam? Oh, that's probably just pain from the incision. The patient's hemoglobin drifts from 12 to 7 in 24 hours? Hell, it's dilutional! Surely he's not bleeding anymore!

I'd sit next to the aforementioned transplant surgeon at M&M meetings in Chicago and he'd just shake his head. What the hell were they waiting for? A return to the OR may not be the crowning achievement of a surgeon's career, but it may very well be the act that saves a patient's life.

7 comments:

rlbates said...

I once cut (by accident) a digital nerve during my fellowship. A complex Dupytren's. My staff surgeon actually complimented me when I recognized my error and immediately asked for the suture I would need to repair it. I never forgot that. In his eyes (and mine) it would have been much worse to have "failed" to see the problem.

Buckeye Surgeon said...

Thanks for sharing Ramona. One's first instinct when things go bad is to deny culpability. And we all know that just makes things worse; for the patient and also in terms of litgation.

Frank Drackman said...

I had to "Take Back" a 4th degree Episiotomy Repair as an Intern. What a mess, like trying to sew bloody ground beef together. No epidural either, only as much 2% plain Lidocaine as I could get to stay in, just asked the patient to let me know if her ears starting ringing.

Anonymous said...

Thanks for the post. Statistically mistakes are unavoidable and, God forbidden, so is death. It makes sense to learn from each other other's mistakes than covering them up or pointing fingers at first sign of trouble. That's what M&M is about, after all.

Devorrah said...

Gross, Frank! You made me cross my legs.

Bongi said...

well you know about my black mamba incident. then there is the common bile duct. not my greatest moment, but as you say, recognize error and fix it. denial has no role here.

Bruce said...

On the other end of the spectrum is the surgeon who just can't leave a wound alone. I remember a case where the surgeon took a patient to the OR six or seven times because "things just didn't look right." I don't think he found much, but he wasn't confident enough to just let it heal on its own.