That Terrible Power

EagleThese have been difficult weeks.

The practice of medicine is one of the most gratifying careers possible, but it is relentless in its demands and unforgiving of imperfections — both those of the patient and the physician. Surgery in particular — while enormously satisfying in its technical and definitive nature for those physicians so inclined and gifted — is at the same time the most humbling of all disciplines. Despite all the training and experience, the knowledge and technical skill acquired through countless repetitions and refinement, things do not always go as planned.

John (not his real name, of course) was like so many others — in good health, early sixties, found to have a rising PSA blood test, which proved to be the harbinger of prostate cancer, fortunately still at an early stage. Presented with the options for treatment, he chose surgery: radical prostatectomy, the total removal of the prostate gland and biopsy of the pelvic lymph nodes — those filters which are the first resting place for cancer cells migrating outside the organ. It was an operation I had performed hundreds of times over nearly thirty years, and promised an excellent chance for cure, with an acceptably low risk of long-term adverse effects.

Surgery began uneventfully, with good exposure of the pelvic organs and lymph nodes, despite his portly habitus which can make such access challenging. The right pelvic lymph nodes were addressed first. Located in a triangular area demarcated by the external iliac vessels — the main artery and vein to the leg — the obdurator nerve (a large nerve deep in the pelvis) and the wall of the pelvic bone below, the lymph glands therein are gently teased and separated from these structures and sent for biopsy.

Surgeons get to know anatomy intimately, and depend on its predictability for safely performing their craft. In this area, the external iliac artery is reliably and predictably located lateral to the vein — farthest to the outside. At times, it can run a somewhat serpentine course, as cholesterol plaques narrow the channel and changes in flow and pressure lengthen and twist the artery. Such variations are also predictable: the artery courses in front of the vein if it moves toward the midline, or else moves away from it, farther toward the outside.

The bulk of the nodes were out in little time, titanium clips sealing the lymphatic channels and small blood vessels which feed them. The final packet was located near the point of the triangle, at the upper part of the pelvis below the vein. Several small vessels were clipped, and these nodes were removed easily as well.

I inspected the nodes, feeling them for firmness that might suggest cancer spread. One node looked peculiar. Hollow. Lymph nodes aren’t hollow.

Shit.

Inspection of the surgical field confirmed my worst fear: I had removed a short section of the external iliac artery, the main vessel to the leg. Located in a highly unusual location: underneath the vein, rather than above and lateral to it — an aberrant knuckle of vascular conduit enveloped in fat and lymph nodes — a section of artery had been cleanly removed with the nodes.

There was no bleeding, and the ends of the severed artery were easily identified and freed up. Fortunately, John did not have advanced vascular disease, and alternate paths for blood flow to the leg were open. A vascular surgeon was contacted, and arrived within 10 minutes. A short synthetic vascular graft was placed to bridge the gap, and full circulation was restored in less than an hour. There was no evidence of ischemia — a dangerous situation where insufficient blood flow and oxygen causes damage to tissue and the release of high levels of toxic lactic acid into the blood.

But the presence of a vascular graft, while salvaging a serious situation, meant something else: the main surgery, the prostate removal, would have to be canceled until the graft healed. To proceed as originally planned would risk contaminating the vascular repair, leading to graft infection — a disastrous complication. The incision was closed, and the patient arrived uneventfully in the recovery room. Two days later, he was home.

Imperfection in a field which demands perfection is perhaps the burden a surgeon experiences most deeply, with the most fear and respect. We hope, by endless years of study, preceptorship, practice, and experience, to master that which cannot be fully mastered, to control and manipulate our world to achieve that which is unachievable.

A surgeon who has never made a mistake is a surgeon who has never operated; the doctor who makes no errors must be one who sees no patients. The hard truth — hardest of any we healers, so often arrogant in our knowledge and skill, must swallow — is that we are not perfect — and neither are our patients.

Such untoward events may occur for many reasons, of course: a surgeon’s inexperience, recklessness, or fatigue, or his inattention to detail and proper technique. Aberrant anatomy, prior surgery, body habitus and underlying disease processes lay additional mines which trigger in unexpected ways and at unplanned times. But in many cases — perhaps even most — such ethical, physical or technical failings contribute little or nothing to a bad result or a poor outcome. Such a claim seems self-serving — and perhaps it is; hence I leave judgment of my own performance in this situation to those wiser and more objective than I — but it has been my experience that such is so with most good, talented surgeons with whom I have worked. The power to heal is the power to harm; the competence to cure the capacity to kill.

I have long marveled at an observation I rarely hear made: that a patient, a complete stranger, after one or two short visits, allows a surgeon to perform what is often a high-risk surgical procedure on their body, with something approaching blind trust. Granted, there is trust accrued in the degree, the board certification, the training, and hopefully the reputation of the surgeon you (or more likely, your family doctor) have chosen. But in reality, the information gap is real, and the leap of faith substantial. The “eyeball test” only goes so far: is the personable, knowledgeable professional you meet in the office a ham-handed clumsy oaf in the OR? Is the obnoxious, cold, arrogant technician a highly competent surgeon (a dichotomy often imagined as the norm), or instead a hot-headed impulsive boor whose ego trumps caution in surgery while denigrating all around him? Fortunately, neither scenario is typical — most surgeons are well-trained, professional, and highly competent — but how will you know?

But even among the highly competent, unexpected or adverse events in surgery are closer to the norm than the exception. Most are trivial and inconsequential — the small vessel cut and easily secured, the important suture which breaks and must be replaced, the surgical dissection which proves tedious and time-consuming rather than routine. Even more serious surgical problems may end up having no discernible impact on the outcome of the procedure, the recovery, or the end results. But serious complications are the bane and bale of every surgeon: our perfectionistic natures strain to demand that it not be so, but reality too often intervenes to correct our hubris and false hopes.

The dashed expectations and frustrated hopes of perfection fall hard on all whom surgery touches — the patient, the family, and the physician. For the patient, there is of course the harm done: the surgery aborted; the longer hospital stay; the pain of additional surgery or procedures made necessary; a temporary or even permanent disability; the disease not cured or ameliorated; even — God forbid — death itself. Both families and patients must bear these losses — and often suffer financial setbacks as well, both in medical costs, lost jobs, wages and benefits forfeited. And the question of, why has this happened? How could it occur? all too often go unanswered, or at best only partially so. Such confusion and frustrations often lead to anger — a potent cocktail whose dregs are often drained in the cold glare of courtroom lights.

For the physician, the demeanor perceived as indifferent or callous is rather the intellectualization and rational detachment which allows the surgeon to perform the vivisection which the untrained would find ghastly. But the cost of such steely objectivity comes in the relationships with those harmed, as empathy and compassion must be recruited from the dark closets to which they were banished long ago, orphans of the very training needed to excel in this field.

And beneath the professional veneer simmers also a cauldron of emotions. Smashing the idol of perfectionism comes hard — though a fragile idol it be — as false conviction that care and competence can avert all disasters is dispensed by the errant knife or misplaced scissors, by dense scarring or genetic quirk. The confidence which carries a surgeon effortlessly through daunting technical challenges melts away in moments, as simple tasks become feared challenges in the light of recent failure. The trust so critical to the patient-surgeon relationship is shaken and battered, and may not survive the event. And the fear: of unforeseen secondary complications arising in the future; of judgement and criticism by peers; of angry families and damaged reputation; of legal implications in an environment where lawsuits are the answer to every problem.

For some the worst wounds are self-inflicted, as shame, self-criticism and depression set in. Like the trapped wolf gnawing at his own leg, we wound ourselves further in vain hopes of escaping the pain and seeking freedom from its ensnarement — only to end up weakened, more vulnerable, and less able to stand. And we strike out at those closest to us, those who wish to help, deepening our isolation. The results can be deadly: scratch the surface of physician suicide — a problem more common than generally recognized — and you will often find the self-destruction engendered when perfectionism collides with poor outcomes.

To greater or lesser degree, many of these reactions were mine in the aftermath of this complication. And there was one other: I was angry — angry with God.

You see, I pray before surgery — and I prayed before this one, for guidance, wisdom, and good judgment, as I often do. If you are of a skeptical bent, and disinclined to give weight to such superstition, at least humor me by accepting that such an act might focus the mind and center the soul. But only a fool would deny that there is much beyond our control — and few things teach this lesson more clearly than surgery. It was not always thus: I have lived a life where skills and talent were all that was needed to succeed — a formula which led me inexorably on a downward spiral of failure. So I pray.

But to pray is to expect answers — and with that lies the unspoken assumption that all will turn out as I would wish. And so, it is God’s fault — is it not? — if the outcome is not what I would desire. Did I not have my patient’s best interest at heart in this request? Would not a good God answer this prayer to the benefit of both me and those He entrusted to my care? And so it appears, ipso facto, that God screwed up — and I get to take the heat. Bum rap, it seems to me.

But maybe — just maybe — there is a bigger picture in all this. Maybe I get to learn how little really is under my control. Maybe I learn to depend more on Him than on myself. Maybe — and this is a tough one — my shortcomings, my imperfections, which can cause harm as easily as my skills beget good — can work beneficially in some unfathomable way, even for those who must bear the suffering of these very imperfections. Some of the worst, most painful episodes in my own life have proven in the long run to be blessings unimaginable at the time — perhaps it can also be thus for others, even when I am the instrument of such adversity. A frightening thought, this — a terrible power.

And what of John? His recovery has been smooth, his lymph nodes show no cancer. I have apologized to him and his wife for this adversity, though no harm was intended nor evident neglect present to my knowledge. I have offered to assist with any financial burden thus accrued. And they have decided to trust me to perform the second surgery — which is humbling and sobering in ways difficult to express.

May God be with me then — and always.

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35 thoughts on “That Terrible Power

  1. Wow. Your pain is palpable, and I can only (put that in quotes) pray that your load will lighten and that the body of adverse consequences will prove to be a temporary burden–and that you will forgive yourself. I am glad for you, and for the patient and his family, that they are willing to trust you again; lawsuits are handy for venting blame and rage, but they rarely, if ever, promote healing of spirit, no matter the outcome.

  2. My ideal of perfection is not a person who never makes mistakes, but one who is competent at dealing with inevitable problems. The personality which most drives me nuts is the one which seizes up in a crisis. (I’m not saying that’s the worst, just the one that makes me bonkers. There’s a coworker of mine who gets stressed out when things start going mildly wrong and it’s my daily task to not show my irritation with her because she’s mostly a nice person with whom I get along. But sometimes she. just. drives. me. nuts.)

    I would be willing to allow a second chance in this sort of situation, particularly in an unusual setup; it seems to me that a surgeon once caught out like this would be more vigilant on the second go-round.

  3. While the answer to your prayer might not have been precisely the one you wanted, your patient appears to have been protected from serious harm. I’m not a big believer in coincidence – having the vascular surgeon close at hand to assist was surely an answer to that prayer. Control? An illusion. One we surrender most unwillingly.

  4. I’ve thought about this sometimes when I sew and make a mistake, or the fabric slips, or the needle breaks. I understand that it is a far humbler occupation, but for some reason surgery comes to mind. I find myself wondering how awful it would be to be unable to so easily repair a mistake and to have to learn under such unyielding circumstances. I shudder for the doctor that the occurance of an incident doesn’t have mere human vanity at stake, but life.

    Thank you all for braving the harsh calling.

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  6. It seems to me that you got what you prayed for…..guidance, wisdom, and good judgement all came to you, though perhaps not exactly when you requested them.
    I enjoy your insights and look forward to reading more.

  7. You might be surprised – and possibly relieved – that patients beat themselves up too when things do not go as planned.

    After experiencing a rare chemotherapy complication several years ago, I partly blamed myself for the fact that after I reported it, it festered unrecognized for another two months. Should I have known how serious it would get? Should I have been more aggressive in insisting that it be more thoroughly evaluated? How could I not have known it was going to cause a problem?

    So yes, I know all too well how incidents like these serve to undermine our trust in our own judgment and our powers of observation.

    The physician does not know I feel partly responsible for the outcome, nor that I understand and forgive the role he unintentionally played. He emotionally withdrew immediately after this incident, so there was never an opportunity to talk about it. I regret very much that when the outcome is less than ideal, patient and physician often are compelled to carry their burden alone. You put the emotional complexities into words – so beautifully, too! – and I thank you for that.

  8. I am a woodworker by profession. (Dear readers, do not construe my humor as criticism aimed at Dr. Bob. His post prompted me to share this.) Just before my prostate, surgery, and moments before I succmbed to the anesthesia, the urologist cheerfully leaned in, “How are you doing?” “Remember”, I said, “Measure twice, cut once.”

  9. Of course, I admire a conscientious, competent surgeon (especially when I need one, as I just did when I was diagnosed with bladder cancer).

    But I equally admire the way you write, both in form and content. I’m not a bad writer, but your writing makes mine look slapdash.

    What I don’t quite understand is how you manage to be both a man of science, as you must be, to do what you do for a living, and a man of obviously sincere faith. Sometimes I wish i had that faith, but I don’t quite get it.

    And I’d let you operate, if I needed it.

  10. Two observations:

    1) I am not a surgeon, but I have had patients where I have been involved with helping them decide about treatments which have included surgery. Occasionally, someone will say while I am trying to explain benefits and risks, “That’s OK, you don’t need to hear any of that. I’ll go with whatever you think is best.” When we are discussing treatments with definite morbidity, and worse potential morbidity, I tell them, “This is not acceptable. You must understand what you are getting yourself into. It’s not me who is having this done, and until I might be actually faced with a decision like this, I’m not sure what I would do.”

    2) I think your dilemma with God is analogous to what I tell patients sometimes, “This illness is the most clear way that God will speak to you. You have to decide whether you will get the message or not.” And it doesn’t matter if they believe in this or that God or any God at all.
    I think your experience was just that — a message from God. Is He showing you your arrogance? Is He testing you? Are you passing the test? You’re the one who must answer these and other questions.

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