Thursday, May 28, 2009

Unable to pull the trigger

I've written before about the hazards of the colostomy takedown. When they go well, the patient is eternally grateful. Nobody wants stool collecting in a belly bag the rest of their life. But we always tell patients that only about 70% of colostomies are reversible after a Hartman's procedure. Sometimes you get back inside a patient who has recovered from perforated diverticulitis and it's just an unholy mess, bowels matted together, anatomy distorted, the pelvis scarred and inaccessible.

Recently I took back one of my nicest patients for a colostomy reversal several months after emergency surgery for a complicated colovesical fistula. It took almost an hour just to get inside his abdomen as I chipped away cell layer by cell layer with the sharp scalpel, separating fascia from bowel. Finally I freed things up and was able to inspect the pelvis. Usually the rectal stump can be easily identified and isolated from the other pelvic structures. In this case, I saw a uniform sheet of peritonealized scar tissue running from the bladder to the sacrum. When the assistant introduced a probe through the anus, I could see a bulge somewhat posterior to the bladder but it wasn't clear to me that there was a distinct tissue plane between the two structures. The rectum was down there somewhere but I wasn't certain exactly where. And for a case like this I think you need 100% certainty. You're taking a patient who was living independently at home, healthy and symptom free, and you subject him to an elective procedure that, if it goes wrong, could potentially adversely alter his existence irreparably. First do no harm. Generally, we surgeons perform operations on ill patients to relieve pain and suffering. This was different. My patient suffered from the psychological pain of having a colostomy, but there was nothing physical or mechanical that reversing his colostomy would make better. So certainty was paramount. It had to be perfect. I dicked around a little while but ultimately I could not pull the trigger. I bailed. I closed him back up and kept his colostomy in place.

Failure in surgery can be defined in a lot of different ways, I've learned over the past three years as an Attending. Errors of omission (laziness, not following up on tests, ignoring a patient's complaints/symptoms) are inexcusable in my mind and I hope that the way I was trained and my own ethic will stave off any future such errors. Conversely, errors of commission are sometimes difficult to identify until one reviews a case in retrospect. Maybe I shouldn't have done that case laparoscopically. Maybe I should have kept those antibiotics on board a few days longer. Maybe I shouldn't have left a drain in that patient. These errors are the ones that keep us up nights and distract us from enjoying a quiet Sunday afternoon at home. The painful deliberation and doubt that creeps in after a completed act. By nature surgeons are aggressive and tend toward the supremacy of action over contemplation. It isn't natural to "do nothing" when a patient comes to us. It's especially hard for a young surgeon to recognize his own limitations, to understand when "action" is actually the wrong course of action.

After my patient awoke from the anesthetic, I went to discuss the operation with him. I wasn't looking forward to it. Even though I know I probably did the right thing, I couldn't evade this feeling of shame, that I had failed him, that I couldn't safely assuage his specific form of pain. I sat down in a chair next to him and spoke quietly, like a penitent schoolboy in the principal's office. I couldn't safely do it, I told him. I apologized. It's OK Doctor, he said. He appreciated my honesty. He's a terrific guy. He recovered uneventfully and went home in a couple days. I've referred him downtown to the Empire to see a colorectal specialist. (Perhaps he can be reversed with some sort of coloanal pull-through procedure which I'm not particularly comfortable doing.)

So no harm was done. My patient will get a second opinion from a specialist who can hopefully give him another shot at getting rid of his colostomy. But I can't seem to shake this hollow feeling that I failed him. Call it youthful hubris, inexperience, whatever. I wanted to be the guy who made him better. It's selfish, I know. It's not supposed to be about me. But maybe I could have done things differently at the original operation that would have made the take down procedure easier. I run things over and over through my mind and I'm consumed with self-doubt and uncertainty. But I think that's ok. It's allright to feel the sting of failure every once in a while. Nobody said this surgery business was going to be an easy gig. You can't get too comfortable. You have to be constantly vigilant for ways to change and improve. I don't want get complacent. I want to get better....

11 comments:

Brian and Jennifer said...

do you cue the "Death Star" theme from Star Wars when you talk about the Empire downtown?

I mean seriously...the place is huge, and it's always under construction!

rlbates said...

Nice post, Buckeye. No words of wisdom, but I know where you are coming from...

Doctor T said...

Buckeye,

When I was in Training (IM) one of our most talented attendings used to say over and over when the care plan was unclear or a patients reponse to intervention could not yet be fully determined: "Don't just do something, stand there!"
This a hard lesson for all of us, especially when illness is critical and the watch and wait approach or the point at which there really is nothing reasonable one can DO feels like lack of knowledge or skill on our parts. (i.e. if he was at Mecca Center would THEY know something to do we don't? Usually not).
But the occasional bystander role can be rewarding in those situations where you watch progress and recovery ensue despite you total lack of having done anything. It is a learned skill to hold the line and WAIT, despite nurseing, patients and your own desire to ACT.
Your post is full of insight.
T.

retired tom said...

The good surgeons know when not to operate...imagine the conversation if you had pressed on and failed...you evaluated what you had in front of you, considered your options and made a decision based upon the ultimate creed... first do no harm...
I bet you a nickel that the mecca does nothing for him...other than a lot of radiological studies that will have a central theme of "maybe, but then again, and on the other hand".

Lizzie said...

I'm on the other side of the equation. I had a difficult reversal and wound up having the colostomy put back one year later. As a patient, I felt like I failed my surgeon. That he tried so hard to complete the reversal and I couldn't tolerate the discomfort. Silly huh? The best outcome for me was learning that living with a colostomy wasn't the end of the world. We all did our best and that's just the way it turned out.

Joseph Sucher, MD FACS said...

I spend a significant portion of my clinical practice caring for patients with abdominal catastrophes derived from all sorts of etiologies; one of them being iatrogenic. Most of the iatrogenic sources are simply complications that all of us face through our career. A few are from suboptimal decision making.

The decision making that we do as surgeons is integral to our success and defines how well our patients will do. Your post is all about decision making and shows us its importance as it relates to patient safety. I hope that your non-surgeon readers continue to pick up on this fact. Find a surgeon who actually THINKS and CARES. This is a surgeon who you can depend on. This doesn't preclude the need to possess technical talent. But generally speaking, the thinking surgeon will be a technically proficient one. Conversely, technical proficiency does not buy you thoughtfulness.

Referring your patient to a specialist is another important point to highlight. It shows a humbleness that is required by us to ensure our egos do not come before our patients health. This is a trait that I have seen laking in some and shine brightly in others. I have no doubt that the specialist will not possess any secret formula for colostomy reversal in a hostile abdomen. It is what it is. But the patient will appreciate knowing that everything that can be done (including this referral) has been done.

Finally, I hope that by being a faithful reader and participant of your blog, you may come to find that those in "the mecca" or "ivory towers" (I happen to reside in the largest medical center in the world) can in fact possess respect for our colleagues outside our walls. Maybe some of your readers will lower their level of disdain for us knowing that we too can be humble, thoughtful and caring.

JFS

Victor Lazaron said...

Important points 1. don't be afraid to back out when proceeding is very dangerous. 2. An honest and humane relationship with your patients will sooth nearly any disappointment. 3. The thought process in surgery is the hard part, nearly anyone can do the technical stuff.

Two last thoughts - Since so many colostomies are ultimately not reversed we are now trying NOT to make them in the first place. I will do a primary anastomosis for most cases of perforated diverticulitis and leave a temporary diversion upstream which is MUCH easier and safer to close in most patients. - Lastly, I too practice in a smaller setting and will refer difficult patients to a tertiary mecca with some frequency, but I might think twice about referring someone like this fearing that they might hurt him by trying an unwise procedure. There is no assurance of good judgement in the big name hospitals (trained there, done that), and nothing at the mothership is going to change fundamentally unfavorable and treacherous anatomy. Now if you send him to a specific surgeon who you know and whose judgement you trust...

Victor Lazaron said...

Important points 1. don't be afraid to back out when proceeding is very dangerous. 2. An honest and humane relationship with your patients will sooth nearly any disappointment. 3. The thought process in surgery is the hard part, nearly anyone can do the technical stuff.

Two last thoughts - Since so many colostomies are ultimately not reversed we are now trying NOT to make them in the first place. I will do a primary anastomosis for most cases of perforated diverticulitis and leave a temporary diversion upstream which is MUCH easier and safer to close in most patients. - Lastly, I too practice in a smaller setting and will refer difficult patients to a tertiary mecca with some frequency, but I might think twice about referring someone like this fearing that they might hurt him by trying an unwise procedure. There is no assurance of good judgement in the big name hospitals (trained there, done that), and nothing at the mothership is going to change fundamentally unfavorable and treacherous anatomy. Now if you send him to a specific surgeon who you know and whose judgement you trust...

Anonymous said...

Something to consider in the future. The objective of the initial operation is to stop fecal contamination of the abdomen. The colostomy does that. But closing the distal end as a Hartmann sometimes leads to the problem you faced. The alternative is to do a mucus fistula. Even if the site of perforation is in the fistula loop, it won't matter. You can close it if you want. But turning out two ends is, in my view, always better than turning out only one. REC

medicblog999 said...

Before I became a paramedic, I used to be a theatre nurse (uk speak for OR nurse). The one thing I learned from working with so many different surgeons, is that I would much rather have a surgeon who thinks about what they the doing and knows their own limits, than the stereo-typical gung-ho surgeon who dives in and goes for the "glory cases" when maybe they aren't experienced or skilled enough to complete the surgery competantly.

Will Smith said...

Good one, thanks for sharing .

ZION CTCA