It's Complicated: The Human Side of Medical Complications

“You lied to me, “ she winced, half joking. “You said it wouldn't hurt.”

“I didn't intend to lie,” I replied, completely serious. “Robotic surgery usually aches a bit, not hurt like this.”

“Maybe I'm just a big baby, then. I thought my pain threshold was higher than this.” Grimacing, she held her lower abdomen. “It hurts really deep, in here.”

“No, I don't think you're being a baby. I think there may be something really wrong.”

I spoke to her with the frank medical familiarity reserved for patients who were in the medical field. “I think you have a hematoma somewhere. We've ordered a CT scan and blood work every 6 hours. Let's put your Foley back in. At least then you won't have to get up. And let's keep you NPO in case we have to go back to the OR.”

“OR? For what?” she returned, denying her pain.

“To fix any bleeders.”

“You said nurses always caused you problems,” she said again, half joking.

“Nurses, doctors' wives…and redheads. Don't know why… but they always seem to give me gray hair,” I joked back.

All kidding aside, the rest of my day was shot. The specter of a complication always hangs over me like the thundercloud above Eeyore. I began tearing apart yesterday's operation, analyzing the surgery with the confidence of a Monday morning quarterback reviewing file footage. So I guess the combination of a brand new scrub tech and a July resident wasn't my brightest position assignment ever. And the fact that I had my head stuck in the robotic control console for a few hours, unable to see what was going on at the operating table, didn't help either.

The scissor that got wedged in the trocar was a huge problem. The advice “just muscle it out” seemed both barbaric and destructive. Despite my resistance, I tried it, and it worked. And although the pneumoperitoneum escaped, I managed to get the trocars back in, but it was tough…and blind…and a little firmer than I expected. Wonder what I hit? Ureter? Iliac? Cava? I must've hit something…and the result wasn't good. It seemed as though the worn out patient safety analogy of “holes in the Swiss cheese aligning” and the patient falling through might actually have some merit.

I then mentally rescheduled my day, deciding which meetings could go and which could stay and which patients absolutely needed to be seen that day. I also considered that tonight was Friday, and the victims of summer revelry would be appearing on the Emergency Department doorstep starting at 4:00 PM, clogging the OR add-on schedule.

I completed the thoughtful analysis with my own personal pity party. The day was ruined. The M and M conference would be really embarrassing with a complication on a prophylactic case. She didn't even have cancer. This surgery was supposed to prevent problems, not cause them. I could hear the snickers already. And, she's a nurse. A nurse who works here. She trusted me and I screwed up. And everyone will know. Excellent.

During my gynecology-oncology fellowship, I learned two conflicting philosophical approaches toward the management of medical complications. The first was, “I'm sorry ma'am, you had a complication,” which laid the problem squarely on the patient. It was simple. I do the operation the same way every time. The patient is the variable: sometimes they heal well, sometimes they don't. When they don't, they have a complication…and I fix it. Although this approach gives the surgeon a degree of separation from the event, allowing clarity to plan the appropriate fix, it always seemed to my Catholic conscience a bit too guiltless. The second philosophy was, “embrace your complications,” which laid the problem squarely on the surgeon. I caused it and I own it. This approach carries a very heavy burden of responsibility, which could at times paralyze even the most level-headed surgeon, requiring one to face the personal demons of guilt and remorse before getting on with the business of fixing the complication. And besides, how was I supposed to embrace it when I didn't even want to hold its hand? It's complicated.

Opting for the second approach, I returned to the scene of the crime.

“You look so much better,” I began, relieved to see most of the pain gone from her face. “And I've got really good news. Your CT scan is normal. Your hemoglobin is 11. With the Foley replaced and the 900 cc of residual urine drained, your narcotic requirement is where it should be. Looks like your complication was only some urinary retention. We'll watch you overnight, but you should be back to normal tomorrow.”

“Thanks,” she said quietly. “I was beginning to really worry. I've seen these things go down before, and after such a bad night I really began to fear the worst.”

We both got lucky that day.

Relieved to feel the storm clouds parting, I realized, only then, how truly selfish my thought process had been. While focusing solely on my terrible day, my complication, my penance, I completely neglected the feelings of this woman who feared for her life. I spent so much energy on pursuing and resolving a nonexistent problem that I overlooked the fact that the simple placement of the Foley catheter had resolved the complication 3 hours ago. So the patient's anguish persisted needlessly.

“Another ghost,” I thought, selfishly.

I call them my “ghosts,” specters of complications past, present, and future. They come to me at night and chase away the sandman, leaving me restless and agitated and, occasionally, quietly tearful in the darkness. I see their withered faces with ill-fitting wigs and dentures, stigmata of my unsuccessful attempts to control their cancer. I hear her fearful voice, reassured by the anesthetist that we would take good care of her during her surgery, an operation from which she never awoke. I smell her perfume and taste the Christmas cookies she baked for us every year when she was well, to show her appreciation. I feel the pain in the pit of my stomach, remembering the supportive husband of 60 years, now a widower, and the phone call expressing my deepest sympathies, which never happened because I couldn't muster the courage. And they all haunt me.

For many years, I tried to exorcise my ghosts and dispel the painful memories of my ineptitude. They always returned, especially during my difficult and vulnerable times. Realizing that they will likely remain with me always, I have rationalized that perhaps I need them. Perhaps they serve another purpose. I now see my ghosts as the spirit of the valuable, albeit difficult, lessons I have learned. Lessons of vulnerability and courage, fear and joy. And above all, humanity.

For despite my unsuccessful attempts to provide it, my patients never ask for immortality or perfection. They simply ask me to do my very best under these difficult circumstances. And usually I can manage that. And with every lesson that each new spirit teaches me, my best becomes just a little bit better.