How to deal with your emotions when a complication occurs during Surgery?

A junior specialist recently asked me “How do you deal with complications: the shame, the gossip, the emotional discouragement and the potential litigation?” This is a topic that we   doctors often do not talk about because it exposes our weaknesses and makes us vulnerable in the eyes of the public and our colleagues.  It is said that the only doctor who does not have any complication is the one who does not operate. One of my friends once told me “ If you go to the mountain often enough you will meet the tiger”. We can’t always run away from complications. We have to try to minimize them and learn to cope when it happens.   Of all the incidents in my life the one thing I hate most is “complications”.

I started private practice at a very early age. In one of my previous articles I have written that I learned most of my skills while in private practice. Robin Sharma wrote “If you are not making a mistake every week you are not progressing”. I have pushed myself all my life so that I could  achieve more. With this attitude, I have suffered my share of complications.   Someone once said that you are not a specialist in a field until you have made all the mistakes that can be made in that particular field. I tend to agree with this. It is easy to try to learn from other people’s mistakes but you learn the most when you yourself make a mistake.

There are several reasons why complications occur. Some of the reasons are:

1. Performing a procedure that is beyond one’s capability
2. A lapse of concentration
3. A faulty medical instrument
4. An assistant’s mistake
5. Fatigue and unwell
6. Just plain carelessness
7. In a hurry

In this article I am not going to talk about how to prevent a complication but more as to how I deal with my emotions when a complication occurs.

I will highlight two situations:

1. A complication which  is recognized during the surgery
2. A complication which is discovered only after a patient has been discharged

1. A complication which is recognized during the surgery 

When I encounter a complication during a procedure or surgery, the first thing I tell myself is to remain calm. Panicking will make the situation worse. I am fortunate that I have a personal nurse who operates with me all the time and I ask her what I should do. She is usually sensible and tells me objectively how I should react. I talk to the anaesthetist to ensure that the patient is stable. If the patient’s condition is stable, I will sit on a chair for a few minutes to think as to what should be my next best move. This will help me decrease my anxiety so that I can think clearly.

If I feel that I need someone else’s help, for example a general surgeon, a urologist or even another colleague, I will ask to call them while I am thinking as to what to do. If I had raised my voice at my assistants due to anxiety, the first thing I will do is to apologise to them. A startled assistant will be a poor assistant.

Once I am calm, I will look at the complication and decide what is the best way of dealing with it. My mind will be racing and thinking of all the other scenarios such as the patient turning bad and possible litigation but I will try to bring my focus back to the present, so that I can deal with the complication safely for the patient.

When the complication occurs during a laparoscopic surgery, the big decision is to decide whether I should do a laparotomy. If the problem is a minor one, I will be better off dealing with it laparoscopically. Of course, this will be done only with the advice of the general surgeon or urologist.  After settling the complication, I will complete the intended surgery. Once the surgery is done, I will check and recheck everything before I close the incisions. I have a checklist at the end of every operation. I will go through it thoroughly, so that nothing is missed. The worse situation is to have a second problem after the complication. I have experienced the misfortune of leaving a gauze in a patient after dealing with a massive haemorrhage during a surgery, so I know when I am agitated and stressed with a complication, I have to be extra vigilant.

Next, I have to decide what to tell the patient. This can be tricky. Should I be really honest and tell the patient that there was a complication and that it was due to my mistake? That would be truly honest. Sometimes,  that is what I do and hope that the patient understands. Most of the time, I  inform the patient that a complication occurred during surgery and due to a difficult situation, I had to take certain necessary steps,  including asking for assistance to fix the problem. It is important for the patient to be aware that if  the bowel or bladder was repaired during the surgery, there is a small possibility that she may need a second surgery if she becomes unwell.

Nurses and other doctors will definitely talk about the complication I faced in surgery. I started performing laparoscopic surgery in 1994 and all my senior colleagues who were against laparoscopic surgery at that time were waiting for me to make mistakes to prove them right. In such an environment, I could not afford any complications because everyone would know it, and all of them would look down on my surgical skills. When a complication occurred, I just had to bite my time and let it pass.

When a complication occurs, my confidence level dips and I feel dejected. My first reaction is to consider stopping doing that particular procedure. However, as I record most of my surgeries I go through the recordings over and over again instead to see where I went wrong. I keep a daily journal and I will write down in detail what happened and how I can prevent it in the future. I go through the text and video many times over the next few weeks so that I learn from any mistake I made and make sure it doesn’t happen again.

Facing the family members when there is a mortally can be even more daunting. I have had one bad experience before. One of my open hysterectomy cases, despite having postoperative anticoagulation prophylaxis, just collapsed on the 3rd postoperative day with a massive pulmonary embolism and died. She passed away in the ICU. That was one one of  the most stressful moments of my life. Every relative who came to see her, scolded me. I offered my sincerest condolences and explained that this happened despite me doing everything right. After taking a bombardment from all the relatives for nearly 3 hours, they took the body and I went back. Fortunately, I did not receive any lawyer’s letter for that case.

It is also fortunate for me that over the last 27 years of my practice, the hospital has not introduced morbidity meetings. We have monthly mortality meetings. Presenting a case during these meetings can be stressful and an embarrassment as other doctors will learn about the event. I just had to brace myself and go through the motion and try to forget the bad experience.

The patient’s bill will be another issue of contention. If the patient has insurance then the extra charges will be covered but if it is a cash-paying patient, the bill will be higher than discussed before the surgery. The patient can be more upset about the higher bill than the complication itself. I usually reduce my fees and speak to the management to help to reduce the hospital portion. I think this is an important practice to reduce the risk of litigation in the future.

Finally, litigation will be a worry. For the next few months, any official looking letter that I receive, will raise by blood pressure as I will be wondering whether it is a lawyer’s letter. This is another stress that one has to go through after a complication.

2. A complication which is discovered only after a patient has been discharged

Now, let’s look at the second situation whereby a complication occurred after the patient has already gone back. The patient will usually call to inform something like “I cannot control my urine and urine is dribbling out of my vagina or I feel like there is some brownish material in the vagina”. I usually receive this phone call during a clinic session. Such phone calls usually get my heart racing. I will not be able to continue with my clinic worrying about a possible complication. I will keep asking myself “how could that have happened? I took all the necessary precautions during the surgery”. I will quickly review the video of the operation to see where I could have possibly made a mistake. Until the patient arrives in my clinic, my mind will be muddled.   After seeing the patient and deciding whether there is a complication, I will have the difficult task of telling her that something had gone wrong and that I need to investigate. Most of my patients would have already been given an edited copy of the recording of their surgery. I will go through the recording one more time with them and tell them that at the end of the surgery everything was fine and this is an unexpected complication. I will then proceed to investigate and get the necessary referral to a general surgeon or a urologist to fix the problem. Since I have good friends in the hospital, they are usually supportive of me. They do not say unkind things about my surgical skills or me. As a result of this, in all occasions, the complications were dealt with, without any litigation and minimal dissatisfaction from the patient.

Advice to young doctors.

One needs a tough mind and personality to face the emotional stresses when a complication occurs. Here is some advice I can give young doctors venturing out to private practice.

1. You will have complications and you have to accept it. It may or may not be your fault but you must learn to cope with it.

2. It is good to be proactive and prevent it. Asking for help is one way to prevent and deal with complications. Don’t be shy to ask a senior colleague for help; do not worry about what he will think of you since he is your direct competitor. Just think of how he can help you solve your complication so that the patient will be well. It is always good to share your risk with others. The more people you bring in to help to deal with a complication the better the chance that the complication will be dealt with well and the patient will feel that you have done your best.

3. Communicate with your patient. The more you talk to your patient and the family the more she will feel that you have done your best and the mishap was beyond your control. Have a family conference and include senior nurse and the administrators. Give ample opportunity for family to vent their anger and frustration.

4. Don’t be dejected and loose confidence in yourself. Tell yourself that it was just one of those days and that, you have learnt from the mistake. You will do your best to prevent it from happening in  future. Talk to your seniors who are more experienced and discuss your complication and how you can prevent it in  future. Many young doctors try to deal with their complications themselves for the fear of shame and this can build up stress in performing the same procedure in the future.

5. Don’t worry about what other people think. Time heals everything and soon nobody will remember the event.

6. Regularly review your work and videos.

7. Have a checklist for before and after surgeries.

8. If you are unwell/fatigue, consider postponing the surgery.

9. Plan your surgeries well. If I have a long operating list, I prefer to do the most difficult cases first when I am fresh and do the easier ones later.

Acknowledgements

I would like to thank my wife Sarojini Palany for editing this article.

I am also grateful to Dr. Gunasegaran P T Rajan for reading through the article and giving good suggestion to improve the article.