A pediatric surgeon can't be too careful

“Have you ever done anything to kill a kid?” Dr. R., the head of the pediatric surgery program, asked me shortly after I had started.

Dr. R. was a slightly stooped, gray-haired man with bushy, unruly eyebrows. The bow tie he wore signaled that he was an absolute expert on every topic in surgery. He rocked back and forth on the balls of his wingtips and looked me in the eye. He was dead serious.

“No, sir. Not that I’m aware of,” I answered.

“Well then, you’re a very lucky person,” he said. “Sooner or later, you will.”

I was not yet accustomed to Dr. R.’s blunt style, but I had five years of surgery residency behind me, and, like a carefully coached defendant sitting in court, I had learned to show no emotion despite what was thrown my way.

Dr. R. rounded daily with me and my fellow surgeons-in-training. Like a pointer tracking prey, he sniffed out all sorts of things we had failed to notice. Was the nasogastric tube truly in the stomach and suctioning the contents properly? Was there skin redness around the IV sites, indicating infection? Had I done a complete physical from head to toe to find the source of that low-grade fever? He seemed picky, obsessive, even obnoxious at times. His incessant questions grated on my nerves, though I knew they served a purpose.

Dr. R. had been in the pediatric surgery business long enough to understand that the hospital is a dangerous place. From the moment a child changes into pink or blue teddy bear pajamas and becomes a patient, each person who comes in contact with him or her is just as likely to accidentally hurt as to help. This especially applies to surgeons because, with our sharp instruments, we stand to do the most damage. If we don’t pay attention to every single detail, no matter how mundane, we are sure to incur a complication.

A medical complication is an unexpected secondary condition that arises in the course of treating a patient’s primary medical problem, the reason for admission into the hospital in the first place.

Some complications are unavoidable. A patient may have an unexpected allergic reaction to a medication, for example, and suffer a cardiac arrest as a result. Other complications are preventable; for example, if antibiotics aren’t given thirty minutes before an incision is made, a patient can develop an infection at the incision site. The infection might be minor and relatively short-lived, or it might spread like a rumor in a sorority house, dissolving skin and sutures and requiring multiple drainage procedures to get it under control. At the very least, such an infection annoys the patient, causes needless physical pain, potentially worsens the scar, and results in additional expense and days missed from work or school.

Complications can also result from technical mistakes that occur in the operating room—tying off a blood vessel that should have been left alone, say, or suturing or cutting too deeply and accidentally damaging a nearby structure. Other complications are the results of errors in judgment—performing the wrong operation at the wrong time or choosing the wrong antibiotic to give before an operation. And then there’s another class of complication, which attorneys refer to as res ipsa loquitur—Latin for “the thing speaks for itself.” This is a kind of error like leaving a sponge or instrument inside a patient; there is no need to bring in experts to debate whether malpractice has occurred here, because this type of mistake, in general, is indefensible. By virtue of the event happening, the verdict has already been decided.

Changing the course of a patient after a major complication can be like trying to steer the Titanic after it has already smashed into the iceberg. Nothing humbles a surgeon like watching a patient lose ground day after day from a series of complications. After all, some, though not all, complications result from mistakes. Medical errors. Every extra day that a patient is in the hospital, the surgeon’s mistake is staring him in the face, a reminder of his imperfection.

One of Dr. R.’s favorite things to do while supervising in the operating room was to recite from memory the worst complication that had ever occurred in association with the particular operation we were performing. This disturbing narrative was not just idle banter. Dr. R. dug out such horror stories to instruct, explaining exactly how such errors could occur, even with the best of surgeons. It might be one of his own mistakes, to which he readily admitted, or it might be somebody else’s, too sensational not to share, sotto voce, as if he were leaning across a Formica table in a coffee shop instead of a patient’s still, anesthetized body.

For example, if we were taking out a spleen, he would recall the time a surgeon in a distant state had taken out a kidney by accident during a routine splenectomy.

“It had to be because of the incision,” he deduced; it must have been too small. There was not enough exposure to get a complete view of the internal organs and their relation to each other. With only a partial view, the surgeon had gotten confused.

I was too focused on the spleen we were taking out to absorb his story fully—or so I thought in the moment. Only later, during other surgeries, did I realize how powerful his telling was: not just the what of it, but the when of it, the lessons spewing forth under the bright lights as we stood with tools in hand, just like the characters in the ill-fated tales.

I know exactly where the spleen is and what it looks like. I don’t think I’ve ever even come close to mistaking it for any other organ. But to this day, every time I take out a spleen, I feel for the left kidney below—a ritualistic palpation inspired by Dr. R.’s horror story.

That our healthcare system is rife with medical errors—errors in diagnosis and treatment, errors in communication, equipment failures that harm patients—became widely acknowledged in 1999 after the Institute of Medicine (IOM) reported that as many as 98,000 patients a year may have died in U.S. hospitals as a result of mistakes. That’s equivalent to a jumbo jetliner crashing (and killing everyone on board) every day. Surgeons operate on the wrong body part approximately forty times per week. Twenty-five percent of hospitalized patients will be harmed by some kind of mistake.

Most experts agree that medical errors are underestimated because, for the most part, they are voluntarily reported. It can also be difficult to capture accurate data because undesirable outcomes and deaths may have multifactorial causes—that is, a patient’s underlying disease or general state of health or age can contribute to a poor outcome in the face of a medical error. In a more recent study from the Journal of Patient Safety, one in which medical errors were counted by experts reviewing charts, the number of premature deaths in hospitals associated with a preventable harm ballooned dramatically, to somewhere between 210,000 and 420,000 patients per year in the United States. This number seems staggering (equivalent to two to four jumbo jetliners crashing every day), but leading healthcare safety experts who reviewed the data agreed that this number was entirely feasible.

One can only imagine the public reaction—and policy response—to two to four jumbo jetliner crashes per day, every day, year after year. So these shocking numbers inevitably raise the question: what kind of shop are we running in healthcare, and how did we get so reckless?

Airlines, as it happens, are often cited as a model of how an industry learns from its mistakes. Detailed cockpit checklists and procedures are followed before takeoff to detect potential mechanical problems on the ground. Every time a plane crashes, the National Transportation Safety Board (NTSB) performs an independent investigation, and the findings are widely broadcast within the industry.

Healthcare, however, has been anything but transparent in publicizing mistakes that harm patients and, compared to other high-risk industries, has been slow to develop reactive practices that enhance patient safety. Fear of lawsuits and the possibility of tarnishing physicians’ and hospitals’ reputations have overshadowed the development of a national system to report and collect data on medical mistakes. During the last decade, however, hospitals, doctors, and the federal government have been putting measures in place to grapple with safety issues. The Agency for Healthcare Research and Quality, a division of the Department of Health and Human Services, was born in the aftermath of the alarming IOM report; its mission is to improve healthcare quality, efficiency, and effectiveness. Its annual budget is roughly 430 million dollars, (66 million of which is earmarked for patient safety)—which sounds like a lot until you compare it to the National Institutes of Health’s 27 billion dollar budget.

The Joint Commission (formerly “JCAHO”), a nonprofit that inspects and grades hospital quality, requires that hospitals report all serious adverse events and perform a root cause analysis of why they occurred. Individual hospitals have instituted programs such as computerized mandatory error reporting and preoperative surgical site marking in an attempt to get control of the medical error epidemic. Some hospitals have even taken the step of hiring a fulltime safety officer, an individual who investigates the causes of medical errors and leads efforts to prevent them.

Many hospitals now require a preoperative timeout before every operation, just like the one pilots perform in a cockpit before takeoff. During this timeout, the operating room team goes through a checklist: the surgical consent is read aloud, the patient’s identity and the operation to be performed are confirmed, and any special conditions, such as a medication allergy, are noted. Communication is established among team members, including the surgeon, anesthesiologist, scrub tech, and circulating nurse. This is an attempt to make sure everyone is on the same page before the operation begins. If not, if anyone in the room senses a problem, she is encouraged to speak up and identify the issue.

Every surgeon I know agrees that the timeout is a great idea. So why did it take so long to implement? Some believe the culture of medicine itself may have impeded the adoption of checklists and other team-based protocols that could alleviate the medical error deluge. Physicians have always been the undisputed decision-makers regarding the treatments of their patients. No one questioned what the surgeon was going to do in the operating room. Everyone assumed he knew which side of the body to open up and what to do when he got in there.

The same top-down approach once dominated the airline industry, with a pilot functioning as the unquestioned authority-in-chief, but that changed after several high-profile plane crashes in the 1970s in which pilot error was key. The aviation industry simply decided that the existing hierarchy would have to be dismantled to make air travel safer.

The patients who die every day as a result of medical errors are spread across thousands of hospitals in the United States; their numbers are diluted in our collective consciousness. If all those bodies were falling out of the sky at the same time, we wouldn’t be able to deny the tragic epidemic of medical errors.

Years after my training with Dr. R., I can still almost feel him in the room with me when I operate. Just as a cold front blowing in makes an arthritic knee begin to ache, his words echo in my ears, and I start to tense up. I hear them now, during what should be a routine case.

We have finally reached the simple part of the operation, after spending two hours working in a newborn’s chest, freeing a wayward esophagus that took a wrong turn during development and fused with the backside of the trachea. Now, we are inserting a simple feeding tube into the stomach of the premature infant. This is the easy part of the case, the part that you can do in your sleep or with one hand tied behind your back. It is the part that should go smoothly and without incident.

The tube is in. We have filled a balloon on the end of the tube to hold it in place and have checked the tube’s position in the stomach, and now we are suturing the tube into place. That is when I see it for the first time, out of the corner of my eye: a tiny wisp of yellow.

“Did you see that?” I ask the surgeon assisting me.

“What?” he says.

“That yellow stuff. Where did that come from?” The fluid inside the intestinal tract is greenish yellow, a mixture of bile and gastric acid. It would be okay if a little bit had leaked out when we made the hole to put the tube in, but there shouldn’t be any leaking out now.

“I didn’t see anything,” he says.

Another trace of yellow crosses my visual field, off to the side of where I am working. I pick up a syringe of saline and wash the area. Now all the fluid is clear, as it is supposed to be. Maybe I was just imagining things.

“It all looks good to me,” my assistant says. “I think we should close.”

He is growing impatient with me. It is Saturday, and he has about a million places where he would rather be than in the eighty-degree heat of this operating room.

“OK, just give me a minute,” I say. I pick up a syringe, attach it to the end of the tube, and flush it with saline water. I’m looking to see if the stomach inflates or if the liquid is leaking out through a hole that shouldn’t be there. The water floods up from behind the stomach. Something is wrong.

“Did you see that?” I ask him. “I think it’s leaking around the tube,” he says. “Maybe you just need to cinch it down with another stitch.”

I put in another suture, wishing, hoping for an easy fix. I, too, want this operation to end. I’m tired. I was on call last night and got very little sleep. I test the tube again. Again, the saline floods up. This time, I’m sure. The saline is not coming from around the tube. There is something wrong. I don’t just suspect it; I feel it now, viscerally.

There has to be a leak somewhere. I don’t know where it is or how it got there, and we can’t tell by looking into the tiny incision we’ve been working through. I take the scalpel and make the opening in the baby’s abdomen bigger. I put in the retractors and start looking around. I look at the stomach first, front and back. I can feel the inflated balloon at the end of the tube, right where it should be. There’s no hole there. Maybe my assistant is right. Maybe I’m just being paranoid. I follow the intestine from its junction with the stomach, around the curve it makes, to where it attaches to the pancreas and the bile ducts.

“Flush the tube,” I tell him, my eyes fixed to that spot. The water wells up, and at that instant, I know exactly where the leak is and how it got there. The tube must have been in too far when the balloon was inflated. Instead of being in the larger reservoir of the stomach, it was in the smaller diameter of the intestine. In the next instant, the balloon was inflated and the tube pulled back and sutured into its proper place. But at some point, the fully expanded balloon ruptured the fragile, thin-walled intestine. It’s one of those complications I’ve never seen but only heard about, in one of Dr. R.’s medical disaster mini-lectures. And now, for the first time, I have come face-to-face with a complication of my own making. My technical error. My mistake.

I reposition the retractors and lift up the duodenum, the first part of the intestine, and that’s when I see the problem. Although in reality it is only millimeters wide, from behind my magnifying glasses, it looks like a sinkhole that’s opened up in the middle of a road, big enough to swallow an entire car. I see only ragged edges and space where the smooth wall of the intestine used to be.

“Damn,” I say, not quite believing what I am seeing. “How did this happen?”

I replay the sequence of events: who was holding what when the tube was inserted, how the tip got shoved in so far, how something like this happened. After the hundreds of feeding tubes I have done, each one executed in the exact same sequence, how did this happen today, to this particular baby?

It is a question I will not be able to answer. Not today. Not ever. I will never know the exact moment the error took place, a fact that will unnerve me the next hundred times I do this procedure.

On February 12, 2009, Continental Connection Air Flight 3407 crashed near Buffalo, New York, killing all forty-nine people on board and one person on the ground. One pilot had reportedly been awake the night before while taking an overnight cross-country flight in a jump seat. The other pilot had been logged into his computer at 3 a.m. and may have slept in an airport lounge. Both pilots could be heard yawning on the plane’s cockpit voice recorder.

The families of the victims were outraged. There had been no major updates to pilot work schedule regulations since the 1960s even though it was well documented that fatigue, like alcohol, can slow reflexes and impair judgment. The National Transportation Safety Board had lobbied for two decades for new rules, but pilot unions and the airlines could not agree on what the limitations should be.

Finally, almost three years after the Buffalo crash, the Federal Aviation Administration (FAA) announced new rules capping at eight (or nine, depending on the time of day and the time zones crossed) the maximum number of hours a pilot could be scheduled to fly and mandating that passenger plane pilots sleep eight hours a day and take a minimum of ten hours off between shifts in the cockpit.

Those changes might have never been made if not for the tragic crash.

It is quite possible—even likely—that exhaustion-related tragedies are happening every day in medicine, but we don’t hear about them unless they are particularly egregious. A major catalyst in reforming resident work hours was the death of an eighteen-year-old woman in The New York Hospital in 1984. Libby Zion was admitted with fever and extreme shaking that progressed to agitation. In the course of her treatment by junior residents who had been working all night, she was allegedly overmedicated and died. Her father, a lawyer and newspaper columnist, filed a lawsuit and brought attention not only to what happened to his daughter, but also to the public safety issues associated with leaving patients to be treated by exhausted residents.

I was in my second year of residency in 1984. At that time a typical workweek was 100-120 hours; our on-call shifts would usually begin at 6 a.m. on the day of call and end, if we were lucky, by 6 p.m. the following day—thirty-six hours later. We have vivid memories of feeling “punchy” by the time the next afternoon rolled around, fighting a heavy blanket of fatigue while struggling to stand upright in the operating room and hold onto retractors. We fell asleep at stoplights while driving home. Sleep deprivation was the one characteristic that united all residents, no matter their specialties or years of training.

Finally, in 2003, concerns over the rate of medical errors by sleep-deprived trainees forced the imposition of an eighty-hour workweek on residency training programs, including a thirty-hour limit on the length of any one shift. A second wave of reforms, which went into effect in 2011, mandated that interns were no longer allowed to work twenty-four-hour shifts.

A 2004 study published in The New England Journal of Medicine, based on data collected before the work-hour reforms took place, found that error rates were 35 percent higher for interns who worked more frequent and longer shifts rather than a schedule that eliminated overnight shifts and reduced the total number of hours worked per week. But early studies tracking the medical error rate before and after the eighty-hour workweek went into effect have found that the number of medical errors did not fall. While these results have been disappointing for proponents of the eighty-hour workweek, several possible explanations have emerged. First, it has been reported that up to two-thirds of residents regularly violate the eighty-hour restriction and work beyond scheduled shifts. The second explanation is the patient handoff, a new wrinkle in patient care that resulted from work-hour restrictions. When residents were working longer shifts, there was more continuity of patient care; with shorter shifts, responsibility for patient care transfers more frequently from one resident to another. The more handoffs, the more potential for errors in communication.

Another factor, no doubt, is that although reforms have restricted the work hours of residents, there are no work-hour restrictions for attending physicians. Surgeons, for example, can still work as many hours as they choose—though studies show that exhausted surgeons, just like exhausted pilots, do not perform at their best.

In every call group I’ve ever been in, one surgeon is routinely scheduled to work from Friday morning to Monday morning—a total of seventy-two hours. The surgeon has absolutely no control over the volume of patients or phone calls he will be asked to handle during the weekend. He can work all day Friday, performing a combination of elective and emergency cases. By Friday night, the surgeon might still be in the hospital, operating, or in bed at home, where he likely takes phone calls from the nurses in the hospital, other doctors needing urgent consults, or the emergency room staff inquiring about patients needing admission. Saturday is spent performing more urgent and emergent operations, and consulting on more patients. By Saturday evening, our weekend surgeon is dragging. He might be groggy and confused when he is awakened, but his shift will continue for another thirty-six hours.

What are the results of such intense and pervasive sleep deprivation on performance? Studies have shown that an individual deprived of sleep for twenty-four hours has the same cognitive function as someone who is legally drunk. The vigilance of three groups of subjects—having four, six, or eight hours of sleep a night—was compared over two weeks. While the eight-hour group had virtually no attention lapses, the reaction time of the six-hour and four-hour groups declined steadily with each passing day; by the end of two weeks, the six- and four-hour sleepers were as impaired as people who had been awake for twenty-four hours straight. What stands out is that even though fatigue was measurably starting to affect their performance, the subjects themselves did not perceive that lack of sleep was affecting them. In fact, they said they felt as capable as ever.

My assistant is deadly silent now as we assess the damage. He knows, as I do, that if we had closed the abdomen before finding this problem, we might have killed the baby. Even now, having discovered the damage, we might cause lifelong complications or even our patient’s death. Two things will make repairing the hole a challenge. First, we don’t have much tissue to work with, and what we do have is tissue-paper thin. Just pulling the edges together enough to close the hole will be difficult. The second issue is that there are other very small tubular structures draining into the wall of the intestine. We have to exercise the utmost care not to obstruct them as we close the hole.

We start at the outer edges, carefully placing delicate, thin sutures in the wall and working our way toward the middle. When the hole is finally closed, I relax just a little; the first, most difficult part is done. Then I fashion a patch over the repair with the omentum, the fatty apron of the abdomen, place a drain in case there is a leak, and close the incision.

Like a quarterback who has just thrown a costly interception, I will not forgive myself until I know whether we have won or lost the game. I won’t get any relief for a week or more— until I finally find out whether everything has healed without yet another complication rising up to smack me in the face. In the meantime, my mistake will jog along beside me on the treadmill where I blast it with the Rolling Stones. My mistake will sit next to me at dinner where I will lose track of the conversation and stare into space. My mistake will lull me to a fitful sleep and pepper my dreams.

When I wake up, I will repeatedly back up the tape to the point where no mistake has yet happened, so that I can make sure that none will happen again.

And I will think about Dr. R. and how he would have woven this mistake into a lesson for trainees too naïve to understand the burdens of all the ways an operation can go wrong, and how devastated they will feel when it does.

About the Author

Catherine Musemeche

Catherine Musemeche is a pediatric surgeon and the author of Hurt: The Inspiring, Untold Story of Trauma Care, from which this essay is adapted. She lives in Austin, Texas.

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