Yesterday I readmitted two patients to the hospital with surgical complications. One was a man who had a colon resection 6 weeks ago. He has had the ‘dwindles’ since discharge. He’s lost weight, has no energy and no appetite. A CBC done yesterday showed his white blood cell count was elevated, and a metabolic panel shows impending renal failure. I suspect he has an intrabdominal abscess despite the fact that he has no fever.
The second patient is 3 weeks out from a complex incisional hernia repair that involved reconstruction of her entire abdominal wall with placement of a large sheet of surgical mesh under the muscle layers. She is a morbidly obese diabetic and has developed a wound infection. If the infection reaches the mesh, I’ll have to remove it, undoing her entire repair.
Complications are a fact of life in surgery. No matter how good a surgeon you are, no matter how carefully you manage patients, something will go wrong once in a while. As my Chief was fond of saying, “If you do big surgery, you get big complications.” Intellectually I know this. But days like yesterday try my soul.
The first thing I ask myself when a patient has a complication after surgery is, “What did I do wrong?” Did I make a technical error? Did I miss some critical sign or lab value? I’m not comfortable until I’ve looked for those things, and even then feel that I must have missed something. This is the default mode for most surgeons I know. That type of thinking is built into our training. The ritual of the Morbidity and Mortality conference emphasizes taking responsibility for everything that happens to your patient. Only then can your peers grant you absolution for your mistakes. I suspect most of us tend to be hyper-responsible pessimists at heart, or we wouldn’t have selected this career in the first place.
The Wise Woman (my wife) tells me that taking responsibility for things I can’t control is arrogant, a form of narcissism that imagines that I am able to control the forces of random chance. I understand her point and accept it. My difficulty is separating those things I can control from those I can’t.
Both of these people had issues before surgery, and that’s another truth I must concede. Trauma is a high-risk practice but even my general surgery practice tends toward the high risk/low reward type of procedures. I’m not sure if that’s a complement to my surgical skill or just because I’m willing to operate on people whom others have turned down. These people are more likely to have postoperative problems than the healthy 33-year-old gallbladder patient. So perhaps the failing isn’t in technical skill or in postop care but rather in judgment and patient selection.
Whatever the root cause of this particular round of surgical complications, I’m still the one who has to clean up my own mess. That is a responsibility any surgeon must accept before he places a knife on the patients skin. Acknowledging the responsibility doesn’t make it any easier to face my patients on rounds in the morning, but at least it helps me sleep at night.